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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)
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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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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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