2015 CBOT Wheat Futures Settlement

CLAIMANT IDENTIFICATION

The Settlement Administrator will use this information for all communications relevant to this Claim Form. If this information changes, please notify the Settlement Administrator in writing. If you are a trustee, executor, administrator, custodian, or other nominee and are completing and signing this Claim Form on behalf of the Claimant, you must attach documentation showing your authority to act on behalf of Claimant.

Section A – Claimant Information

Is the Beneficial Owner an Individual?

Is the Beneficial Owner an Entity?

Representative or Custodian Name (if different from Claimant[s] listed above):

Address 1: *

Address 2:

Country: *

City: *

State/Territory: *

Zip: *

Telephone Number (home or cell): *

Telephone Number (work):

Email Address (If you provide an email address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.):

* Denotes required field

Section B – Authorized Representative Information

Name of the person you would like the Claims Administrator to contact regarding this Claim (if different from the Claimant name):

Telephone Number (home or cell):

Telephone Number (work):

Address 1:

Address 2:

Country:

City:

State/Territory:

Zip:

Email Address (If you provide an email address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.):

TABLE OF TRANSACTIONS IN CBOT WHEAT FUTURES OR OPTIONS

Complete this Part IV if and only if you entered into transactions in CBOT Wheat Futures or Options from February 1, 2015, through May 15, 2015. Do not include information regarding instruments other than CBOT Wheat Futures or Options and do not include transactions in CBOT

List of Brokers or Nominees

Please list all brokers or futures commission merchants (“FCMs”) at which you maintained accounts in which you traded or held CBOT Wheat Futures or Options.

Broker Nominee Name:

Must click Add Entry to save your information.

Broker or Nominee

Action

List of Account Names and Account Numbers

Please provide a list of all account names and account numbers for each entity you listed in response above in which you traded or held CBOT Wheat Futures or Options.

Account Name:

Account Number:

Must click Add Entry to save your information.

Account Name

Account Number

Action

CLAIM DETAIL TRANSACTIONS

For your Wheat Futures and Option contracts provide your end of day positions and average price as of January 31, 2015. For each purchase or sale of Wheat Futures or Option contracts during the Class Period please provide the required information for each transaction. For your Wheat Futures or Option contracts please provide your end of day positions and average price as of those as of May 15, 2015.

CLAIM DETAILS TRANSACTIONS

Security Type:

Transaction Type:

Trade Date:

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Average Price: *

Net Position (Long/Short): *

Confirm Proof Enclosed:

Trade Date:

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Average Price: *

Net Position (Long/Short): *

Confirm Proof Enclosed:

Trade Date: *

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Transaction Price: *

Brokerage Firm:

Account Number:

Confirm Proof Enclosed:

Trade Date: *

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Transaction Price: *

Brokerage Firm:

Account Number:

Confirm Proof Enclosed:

Trade Date:

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Average Price: *

Strike Price: *

Net Position (Long/Short): *

Call Or Put: *

Confirm Proof Enclosed:

Trade Date: *

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Transaction Price: *

Strike Price: *

Expiration:

Call Or Put: *

Expiration Date: *

Brokerage Firm:

Account Number:

Confirm Proof Enclosed:

Trade Date: *

Contract Code:

Contract Month: *

Contract Year: *

Number Of Contracts: *

Transaction Price: *

Strike Price: *

Expiration:

Call Or Put: *

Expiration Date: *

Brokerage Firm:

Account Number:

Confirm Proof Enclosed:

Trade Date: *

Contract Code:

Contract Month:

Contract Year:

Number Of Contracts:

Average Price:

Strike Price:

Net Position (Long/Short):

Call Or Put:

Confirm Proof Enclosed:

Must click Add to save your information.

Security Type

Transaction Type

Contract Code

Contract Month

Contract Year

Trade Date

Quantity

Price

Strike Price

Option Type

Trade Status

Status Date

Broker Name

Account

Net Position

Proof of Purchase Enclosed

Action

UPLOAD SUPPORTING DOCUMENTS

All supporting documentation for your positions and transactions should be uploaded to this page prior to moving on to the next step in your online claim submission.

Please use the browse option, by clicking on “Select Files” in the box below, to upload your supporting documentation being submitted to verify all of your positions and transactions.

Select files

Files To Be Uploaded	Size	Action

CLAIMANT’S CERTIFICATION & SIGNATURE

Certification

BY SIGNING AND SUBMITTING THIS CLAIM FORM, CLAIMANT OR CLAIMANT’S AUTHORIZED REPRESENTATIVE CERTIFIES ON CLAIMANT’S BEHALF AS FOLLOWS:

1. I (we) have read the Notice and Claim Form, including the descriptions of the Release and Covenant Not to Sue provided for in the Settlement Agreement;

2. I (we) am (are) a Class Member and am (are) not one of the individuals or entities excluded from the Settlement Class;

3. I (we) have not submitted a Request for Exclusion;

4. I (we) have made the transactions submitted with this Claim Form for myself (ourselves) and not as agents of another, and have not assigned my (our) Settled Claims to another;

5. I (we) hereby warrant and represent that I (we) have not assigned or transferred or purported to assign or transfer, voluntarily or involuntarily, any matter released pursuant to the release or any other part or portion thereof;

6. I (we) have not submitted any other claim in this Action covering the same transactions and know of no other person having done so on his/her/its/their behalf;

7. I (we) hereby consent to the disclosure of, waive any protections provided by any applicable bank secrecy or data privacy laws (whether foreign or domestic), or any similar confidentiality protections with respect thereto, and instruct Settling Defendants or any authorized third party to disclose my (our) information and transaction data relating to my (our) trades for use in the claims administration process;

8. I (we) submit to the jurisdiction of the Court with respect to my (our) claim and for purposes of enforcing the releases set forth in any Final Judgment that may be entered in the Action;

9. I (we) agree to furnish such additional information with respect to this Claim Form as the Settlement Administrator or the Court may require; and

10. I (we) acknowledge that I (we) will be bound by and subject to the terms of the Final Judgment that will be entered in the Action if the Settlement is approved.

Signature

PLEASE READ THE RELEASE, CONSENT TO DISCLOSURE, AND CERTIFICATION, AND SIGN BELOW.

I (we) acknowledge that, as of the Effective Date of the Settlement, pursuant to the terms set forth in the Settlement Agreement, and by operation of law and the Final Judgment, I (we) shall be deemed to release and forever discharge and shall be forever enjoined from prosecuting the Settled Claims against the Released Parties (as defined in the Settlement Agreement and/or Final Judgment). I (we) shall not hereafter seek to establish liability against any Released Party or any other Person based on the facts, conduct, or events during the Class Period underlying this Action.

By signing and submitting this Claim Form, I (we) consent to the disclosure of information relating to my (our) transactions in CBOT Wheat Futures or Options during the Class Period, and waive any protections provided by any applicable bank secrecy or data privacy laws (whether foreign or domestic), or any similar confidentiality protections with respect to information and transaction data relating to my (our) trades, for use in the claims administration process.

If signing as an Authorized Representative on behalf of an entity, I (we) certify that I (we) have legal rights and authorization from the entity to file this Claim Form on the entity’s behalf. UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA, I (WE) CERTIFY THAT ALL THE INFORMATION PROVIDED BY ME (US) ON THIS CLAIM FORM IS TRUE, CORRECT, AND COMPLETE AND THAT THE DATA SUBMITTED IN CONNECTION WITH THIS CLAIM FORM ARE TRUE AND CORRECT COPIES OF WHAT THEY PURPORT TO BE.

NOTE: If you have been notified by the I.R.S. that you are subject to backup withholding, please strike out the language that you are not subject to backup withholding in the certification above.

Signature of Claimant (if Beneficial Owner is an individual filing on his or her own behalf): *

Authorized Representative Completing Claim Form (if any):

Capacity of Authorized Representative (if other than an individual, [e.g., trustee, executor, administrator, custodian, or other nominee]):

REMINDER: YOUR CLAIM FORM AND REQUIRED DATA MUST BE SUBMITTED ONLINE BY 11:59 P.M. EASTERN TIME ON JANUARY 16, 2023, OR POSTMARKED AND MAILED NO LATER THAN JANUARY 16, 2023.