Foreign Claim Form

MDL 926 (BREAST IMPLANT LITIGATION) -- FOREIGN CLAIM FORM under FSP
(Return this form only if you may be eligible under FSP)

FOREIGN CLAIMANT'S NAME

Birth Date

MDL Registration No.

Last Name

First Name

Mon

Day

Year

CLAIMANT'S CURRENT ADDRESS

Street Address (or P.O. Box):

Additional Address Information (if needed)

City:

State/Province:

ZIP/Postal Code:

Country:

FOREIGN CLAIMANT'S ATTORNEY INFORMATION

Check one (but only one) of the following blocks:

[ ]

I am not represented by an attorney. Remove name of any attorney previously shown as representing me.

[ ]

I am represented by the following attorney. Remove any other attorney previously named as representing me.
(Provide the information below only if you are being represented by an attorney.)

Attorney's Name:

Name of Attorney's Firm (if any):

Street Address (or P.O. Box):

Additional Address Information (if needed)

City:

State/Province:

ZIP/Postal Code:

Country:

To assure proper recording and filing, print legibly and IN ENGLISH; use your previously assigned MDL Registration number. If data exceeds spaces provided, use first letters/numbers that will fit in spaces.

Check one (but only one) of the following blocks:

[ ]

I do not want to participate in the RSPF even if eligible. (Check only if you want to "opt out" of the RSPF.)

[ ]

I may be eligible and may want to participate in the RSPF. Please determine my eligibility and status under the RSPF. (If this option is checked, you must return this form to the Claims Office in time to be received by June 15, 1999, completing the information indicated below and also providing supporting documentation of your breast implants and a copy of a governmentally-issued identification card.) To participate in the RSPF, you must provide the following information for each Bristol, Baxter, or 3M implant (or set of implants) possibly covered under the RSPF and for each Dow Corning implant (or set of implants) you have had. Use back of form if you have had more than five such implants (or set of implants).

Proof of Mfr.

Approximate

If explanted,

Attached

Already

Date Implanted

Brand or Manufacturer

approx. date

w/form

provided

(Mon/Yr)

of implant

(mon/year)

[ ]

________________

_______________________________________

________________

[ ]

________________

_______________________________________

________________

[ ]

________________

_______________________________________

________________

[ ]

________________

_______________________________________

________________

[ ]

________________

_______________________________________

________________

I declare under penalty of perjury that the above information (and any information added on the back of this form) is--to the best of my knowledge, information, and belief--true, accurate, and complete. I expressly declare that, if I have received any implant identifiable as manufactured by Dow Corning, it is listed on the front or back of this form.

_________________
Date Signed

______________________________________________
Signature (Claimant or Court-Appointed Representative)
(Not Attorney unless Court-Appointed Representative)

See Instructions and Explanation on back of Form

(Back of Foreign Claim Form)

Instructions and Explanation for Foreign Claim Form under Foreign Settlement Program

Complete and return this Form to the Claims Office if, but only if, you registered by March 1, 1995, with the Claims Office as a Foreign Claimant under the original global settlement and believe you can establish you have had at least one Bristol, Baxter, or 3M breast implant covered under the FSP. Details concerning eligibility are contained in paragraph 4 of the FSP Notice, and a list of implants covered under the FSP is contained in Exhibit G2 to the Notice.

For you to participate in the FSP, the Claims Office must receive by June 15, 1999, the following:

(1)		This Form, completed IN ENGLISH and signed by you or your court-appointed representative (such as a Guardian). The Claims Office cannot accept a form signed by your attorney (unless also serving as a court-appointed Guardian or other legal representative). The Form should list each Bristol, Baxter, or 3M implant (or set of implants) covered under the RSPF, as well as each Dow Corning implant (or set of implants).
(2)		Acceptable proof of at least one Bristol, Baxter, or 3M breast implant covered under the FSP. Exhibit G2 contains detailed instructions as to what is acceptable proof. (If the original records are not in English, you should provide a copy of the original foreign-language records, but also attach a translation of these records into English, accompanied by the translator's statement (under penalties of perjury) that the translator is proficient in English, that the records (or the translated portions thereof) have been correctly translated, and that the translator has no personal or business relationship with you or your attorney.) Some foreign-language medical and hospital records may be acceptable without need for English translations; see paragraph 22 of the Notice and Exhibit G2 for further information
		While you are required to list on this Form any Dow Corning implants, you are not required to provide proof of your Dow Corning implants If you will not be attaching proof of manufacturer to this Form because you have previously submitted documentation of your implants to the Claims Office, you should promptly file this Form with the Claims Office. A delay in filing could, if there is some deficiency or problem with this previously-provided proof, result in your not being so advised by the Claims Office in time for you to correct the problem by the June 15, 1999, deadline. If you have not previously submitted this proof, it is recommended that you wait to file this Form until you can obtain and attach the necessary proof. However, be aware of the June 15, 1999, deadline--which is the date by which the Form and proof must be received by the Claims Office (not merely mailed)
(3)		A copy of a governmentally-issued card identifying you and containing your photograph and signature. Examples of such cards are passports, national insurance identification cards, and driver's licenses.

Use space below if you need more space to provide information called for on the front of the Form

Copies of this Form may be used in submitting claims, but any reproductions must include the identical information, require the identical data, be in English, and be in substantially the same format as this Form.

If you have further questions, read the Notice and Exhibits [available from the Internet]; contact your attorney; or call 1-800-600-0311 (toll-free in U.S.) or 713-951-9106