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Filling Out Your Claims Form

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Section 1: Claimant Information

Find all Claim forms on the official Claims website: http://officialflintwatersettlement.com.

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This information should be auto-populated from your Registration form. Please read through to ensure it is accurate and complete.

Examples of the Claim Form
Section 1

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Section 2: Next Friend, Personal Representative or Guardian Information

This information should be auto-populated from your Registration form. Please read through to ensure it is accurate and complete. If circumstances have changed, please update the information.

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Be prepared with the necessary documentation establishing your legal authority to be submitting a claim on someone else's behalf. See table below for a list of required documents.

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If you are representing a deceased claimant, you will need to establish an Estate in their name. See the steps on the flyer below.

Section 2

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Required Documentation for Representation

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Setting up an Estate for
a Deceased Claimant

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Click here to download for printing.

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Section 3: Attorney Information
This information should be auto-populated from your Registration form. Please read through to ensure it is accurate and complete. You do not have to be represented by an attorney to participate in the settlement.

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Section 3

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Section 4: Flint Water Settlement Categories

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Select the Settlement Category or Categories that best fit(s) the claimant.

 

Multiple categories are possible.

 

The Claim Form Instructions have a full explanation of each category, including quick-reference tables for each category. View, download, or print.

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Structured Settlement for Minors

A structured settlement form must be submitted prior to notices being distributed. If no form is submitted, all awarded funds are put into a trust.

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Click here for a sample form.

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Section 4

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Section 5: Verification
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This information should be auto-populated from your Registration form.

 

Ensure that your signature or
e-signature is affixed to the Claims Form.

Section 5

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Declarations

In addition to a Claims Form, you will complete a Declaration or Declarations. Some of this information will auto-populate from Registration Form.

 

The declaration type is determined by the settlement category:

  • Categories 1-27: Exposure

  • Category 28-30: Real Property Owner/Renter or Business Owner

  • Category 29-30: Business Interruption​

Exposure Declaration

In order to show exposure, fill out the following information on the Exposure Declaration Form:

  1. Your name.

  2. If you are completing the form on behalf of another person, their name.

  3. Identify the type of Claimant.

  4. List all residences that you occupied since April 25, 2014.

  5. Identify places other than residence where claimant was exposed to Flint water like workplace, school, or daycare.

  6. If your period of exposure was between April 25, 2014 and July 31, 2016, then answer Yes.

  7. If your period of exposure was between August 1, 2016 and November 16, 2020, then answer Yes.

  8. Only answer Section 8 if you were diagnosed with Legionnaires disease.

Exposure Declaration

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Real Property Owner/Renter or Business Owner Declaration

Fill out the following information on the Real Property Owner/Renter or Business Owner Declaration Form:

  1. Your name.

  2. Address of the affected property.

  3. Name of business (if applicable).

  4. Names of all owners, lessees, or interested parties.

  5. Names of all owners or interested parties of the business. 

Real Property Owner/Renter or Business Owner Declaration

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Business Interruption Declaration

Fill out the following information on the Business Interruption Declaration Form:

  1. Your name.

  2. Address of the affected real property/business.

  3. Name of business.

  4. Describe the property damage or business economic loss between April 25, 2014 and July 31, 2016.

  5. Describe your claimed amount of damages and how you determined the amount. 

 

Note: Tax documents must be submitted in conjunction with this Declaration Form.

Business Interruption Declaration

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Release Form

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  • A standard release form is required to affirm no further legal action will be taken against the settlement defendants.

  • Each claimant (or their representative) will need to sign a release in order to participate in the settlement.

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Lien Disclosure Form

 

ALL claimants must fill out and sign a Lien Disclosure Form.

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Signature Attestation Form

  • A signature attestation form is required to affirm no further legal action will be taken against the settlement defendants.

  • Each claimant (or their representative) will need to sign a release in order to participate in the settlement.

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Release
Supporting Documentation

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All Claimants who are filing an Exposure Declaration will provide one or more of the following supporting documents:

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  • Water bill in the Claimant’s name for each residence or business for which you lived/worked or paid a water bill between April 25, 2014 and November 2020; 

       Note: Please check your records or any online statements 

       before requesting copies of water bills from the City.

OR

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  • School Record of attendance between April 2014 and November 2020, showing the address of the school and your name OR minor child’s name and address (showing Flint address of school and/or Claimant);

       Note: If you and your minor child were both students, please

       submit records for all claimants separately.

OR

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  • Day Care Invoice dated between April 2014 and November 2020, showing the address of the Day Care and your child’s name (showing Flint address of day care location and/or Claimant);

OR

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  • Letter from employer verifying employment at a business in Flint between April 2014 and November 2020 with address (showing Flint address of place of employment and/or employee);

OR

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  • Check or pay stub for a business in Flint between April 2014 and November 2020 with address (showing Flint address of place of employment and/or employee);

OR

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  • Tax return showing each address where you lived in Flint between 2014 to 2020;

OR

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  • Deed to property located in Flint during the relevant category Exposure Period showing name of Claimant on deed;

OR

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  • Deed, lease, or mortgage statement for each residence or business for which you lived/worked or paid a water bill between 2014 to 2020;

OR

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  • Other document sufficient to reliably show address of Claimant’s exposure to Flint water during the relevant category Exposure Period. The Claims Administrator will follow up with you if necessary after their review of the documentation provided.​

Medical Records:

Provide relevant medical records from your physician if you suffered from any of the following and were treated by a medical professional (for visits/treatments between April 25, 2014 and November of 2020):

  • Preterm birth – if your child was born prior to 37 weeks or born weighing less than 5 lbs 8 oz; 

  • Miscarriage; 

  • A minor was formula fed with Flint water;  

  • Severe hypertension; 

  • Neuropathy; 

  • Stroke; 

  • Anemia; 

  • Renal insufficiency; 

  • Skin rashes or lesions; 

  • Hair loss; 

  • Respiratory problems; 

  • Pneumonia; 

  • Gastrointestinal conditions; or 

  • Legionnaire’s diagnosis.

Test Results:

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If you have had any of the following tests performed with documented results, please provide them to support your claim: 

  • Any cognitive deficiency tests (of a minor) from May 16, 2014 to date; 

  • Any blood lead level test results from May 16, 2014 and August 31, 2016; 

  • Any bone lead test results from May 16, 2014 to date; 

  • Any home water test results from May 16, 2014 to August 31, 2016. Online source here.

Legal Authority to File for Another:

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If you are completing forms on behalf of someone else:   

  • If you are completing forms on behalf of a minor child, please gather the minor’s birth certificate and any other documents showing guardianship or adoption, as applicable; 

  • If you are completing forms on behalf of a decedent, please gather the decedent’s death certificate and estate papers; 

  • If you are completing forms on behalf of a business, please gather the certificate of incorporation and tax records from 2012 to present. 

All Claimants who are filing Real Property Owner/Renter or Business Owner/Interruption Declarations must provide at least one of the supporting documents listed below:

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  • Water bill in client’s or business name during exposure period

  • Tax return during exposure period

  • Deed, Lease, or Mortgage statement for Flint property with client’s name

SupportingDocs
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