Common use of Certification, Authorization, and Signature Clause in Contracts

Certification, Authorization, and Signature. By submitting this Claim Form, I agree to be bound by the terms of the Agreement and the jurisdiction of the Special Master, and the court presiding over MDL No. 1964, the federal multi-district litigation venued in the United States District Court for the Eastern District of Missouri (the “MDL Court”) (or the New Jersey Coordinated Proceeding Court, should the MDL Court lack subject matter jurisdiction), with regard to all matters pertaining to the Agreement and the Program contained therein. I agree that the Special Master will hea motions to dismiss claims that fail to comply with the Agreement and make recommendations to the court in which my case is pending. I also agree that appeals of determinations by the Claims Administrator as to whether a Claimant is eligible for payment under the terms of the Master Settlement Agreement will be resolved by the Special Master, and that the Special Master’s decisions will be binding on the parties. I acknowledge that the Special Master’s rulings on these appeals are separate from recommendations he makes as a Special Master on appointment from the MDL Court, New Jersey Coordinated Proceeding Court, or other court. By executing this form, I acknowledge that I have been fully advised of my rights under the Agreement and elect to participate in the Program, and that such election is irrevocable. I declare under penalty of perjury subject to 28 U.S.C. § 1746 that all of the information provided in this Claim Form is true and correct. Claimant’s Signature Date / / (month) (day) (year) Printed Name First MI Last IN RE NUVARING® PRODUCTS LIABILITY41L5I3T8IGATION APPENDIX E-2 Patient Name First Middle Initial Last Date of Birth: / / (Month/Day/Year) Social Security No. | | | | - | | | - | | | | |