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Case 3:12-cv-00519-GCM Document 121-1 Filed 01/31/13 Page 1 of 24

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Claimant Information

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Registration Verification

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Registration  Complete

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Claim Types (Please check any/all that apply)

Affiliate

Retail Auction User

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Affiliate

This screen will be displayed only if this Claim was selected.Case 3:12-cv-00519-GCM Document 121-1 Filed 01/31/13 Page 7 of 24

Affiliate (continued)

This screen will be displayed only if this Claim was selected.Case 3:12-cv-00519-GCM Document 121-1 Filed 01/31/13 Page 8 of 24

Retail Auction User (Individuals that purchased retail bids for use on ZeekRewardsauction sites; not participants in the multi‐level marketing program)

This screen will be displayed only if this Claim was selected.Case 3:12-cv-00519-GCM Document 121-1 Filed 01/31/13 Page 9 of 24

Trade Creditor or Independent Contractor

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This screen will be displayed only if this Claim was selected.Case 3:12-cv-00519-GCM Document 121-1 Filed 01/31/13 Page 10 of 24

Former Employee or Officer

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Taxing or other Governmental Authority

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Subrogation Claim of Financial Institution

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Other (Please upload supporting documentation detailing the basis of your claim)

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Payments Made to ZeekRewards

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Payments Received from ZeekRewards

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Claim Summary

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Additional Information/Questions

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Additional Information/Questions (continued)

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Additional Information/Questions (continued)

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Consent to Jurisdiction

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Claimant Signature

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Clicking the Submit button will mark your claim as complete.  You will no longer be able to alter your claim.

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