Fix Claim - Avis Mendez Settlement

The deadline for submitting this proof of claim form is

Contact Information

Provide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this form.

First Name *

Last Name *

Street Address 1 *

Street Address 2

City *

State *

Zip Code *

Country *

Email Address *

Phone Number *

* Required Fields

e-Toll Related Charges

Defendants maintain records of the e-Toll-Related Charges Class Members paid during the Class Period for Avis and Budget rentals. Defendants’ records will be used to calculate the value of your claim under the terms of the Settlement Agreement. You can obtain the information used to calculate the value of your claim by calling the Settlement Administrator at 1-844-448-0078, or by emailing Info@eTollSettlement.com. If you don’t want to rely on Defendants’ records, you may submit any and all records or other proof to show your payment of e-Toll-Related Charges on Avis or Budget rentals during the Class Period. Upload copies of your proof with this claim form. Please keep any original documents.

Select one of the following:

I agree to be paid based on the e-Toll-Related Charges contained in Defendants’ records:

Yes - Proceed to Payment Method.

No - Complete the chart below and provide proof with this claim form.

List Transactions

You do not need to fill out this chart unless you disagree to be paid based on the e-Toll-Related Charges contained in Defendants’ records.

Approximate Rental Date (Month, Year)	Vehicle Pickup Location	e-Toll-Related Charges You Paid	Refunded Amount^†	Third Party Billed^‡
Approx Rental Date*	Location*	Charges Paid*	Refunded Amount*	Yes
Approx Rental Date	Location	Charges Paid	Refunded Amount	Yes
Approx Rental Date	Location	Charges Paid	Refunded Amount	Yes
Approx Rental Date	Location	Charges Paid	Refunded Amount	Yes
Approx Rental Date	Location	Charges Paid	Refunded Amount	Yes
Approx Rental Date	Location	Charges Paid	Refunded Amount	Yes
Approx Rental Date	Location	Charges Paid	Refunded Amount	Yes

^†If you received a refund from Avis Budget Group, Inc. or the Highway Toll Administration LLC for this transaction, enter the refunded amount here.

^‡If the e-Toll-Related Charges were paid directly by a third-party through a central billing account, check “YES” here.

Fill Out and Sign the Following Attestation

By signing below, I certify that, at the time I used the e-Toll service, I was not aware that such use required payment of additional fees or charges.

I declare under penalty of perjury under the laws of the United States of America that the information provided on this form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review.

Signature *

Date

Your Claim Form has been updated successfully.

Please print this page for your records.

Your Claim Details
Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
Last Name
Street Address
Street Address 2
City
State
Zip Code
Email Address
Phone Number

Signature
Date

If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@eTollSettlement.com

Click here to edit your Claim.

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Mendez v. Avis Budget Group, Inc. et al.

Case No. 2:11-cv-06537-CCC-JSA (D.N.J.)

United States District Court for the District of New Jersey

The deadline for submitting this proof of claim form is

Your Claim Form has been updated successfully.