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CLAIM NO.: (To be completed by Settlement Administrator) |
If you have questions about this Release, consult with your attorney. If you do not have an attorney, contact Class Counsel. You must sign this Release and return it to the Settlement Administrator before your claim can be paid.
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___________________________ Class Member's Last Name |
__________________________ First Name |
______________________ Social Security Number |
I am a participant in the Class Action Settlement Agreement Re Gammagard® Intravenous Immune Globulin Claims ("Agreement") approved by the United States District Court for the Central District of California.
In return for receiving payment or payments under that Agreement, I release and discharge BAXTER HEALTHCARE CORPORATION and BAXTER INTERNATIONAL INC. ("Baxter"), and all of its present and former corporate parents, subsidiaries, affiliates, divisions, partners and joint venturers, as well as all suppliers, distributors, pharmacies, medical providers and any other person or entity, and all shareholders, directors, officers, employees, agents, servants, persons, insurers, reinsurers and counsel of each of the foregoing, as well as their predecessors and successors, from any and all claims I may have now or in the future relating in any way to alleged exposure to and/or infection with hepatitis C arising out of the infusion, administration, receipt or use of or contact with Gammagard® IVIG during the period from January 1, 1993 to February 24, 1994.
I understand that this Release does not extinguish rights I might have to Additional Payments under the Agreement, but does extinguish all other claims, lawsuits, causes of action and demands for losses and damages of every kind, including but not limited to, damages for personal injuries, death, mental or physical pain or suffering, loss of income, earnings and earning capacity, doctor bills, hospital bills, nursing costs, drug or pharmaceutical costs, medical monitoring, loss of consortium, companionship, society or affection, damage to familial relations, loss of enjoyment of life, economic, business or contractual losses, punitive or exemplary damages, statutory damages, interest, costs, attorneys' fees, or any other compensation or relief whatsoever, whether known or unknown, foreseen or unforeseen, suspected or unsuspected, whether in law or in equity, or before administrative agencies or departments, that I ever had, now have, or hereafter can, shall or may have, relating in any way to alleged exposure to and/or infection with hepatitis C arising out of the infusion, administration, receipt or use of or contact with Gammagard® IVIG during the period from January 1, 1993 to February 24, 1994.
I understand that this Release is intended to discharge and extinguish not only those claims which I have or may have against Baxter but also those claims that could be brought by others, including my spouse, children, heirs, estate, beneficiaries, successors, subrogees, assigns, executors, attorneys, agents or any other legal representatives, including but not limited to wrongful death and survival actions.
I agree to cooperate fully and to execute any and all required documents and to take any additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Release.
I represent and warrant that I have not sold, transferred, conveyed, assigned or hypothecated any rights, either collectively or individually, in whole or in part, in any of the matters released herein.
I agree to assume exclusive responsibility for the payment of any lien or liens, past, present or future, known or unknown, by any person, entity, business, firm, corporation or government entity or agency relating in any way to alleged exposure to and/or infection with hepatitis C arising out of the infusion, administration, receipt or use of or contact with Gammagard® IVIG during the period from January 1, 1993 to February 24, 1994, including but not limited to medical expenses paid for or reimbursed by private health insurers, Medicare, Medicaid, or any other public health insurers.
I agree that if the Agreement is changed or vacated in any way, this Release will remain in full force and effect so long as I receive all of the same payment or payments for which I am eligible under the Agreement.
I agree that this Release shall be governed, construed and interpreted in accordance with the laws of the State of Illinois.
I understand and agree to the terms of this Release. I had an opportunity to consult attorneys of my own choice to solicit advice with respect to my rights and the meaning and effects of this Release and, if I did not consult an attorney, I knowingly and voluntarily elected not to do so.
I have full power and authority to make, execute and deliver this Release and am under no legal disability material to my ability to execute this Release. I have carefully read this Release, signed it as my own free act, and intend to be legally bound thereby.
I declare under penalty of perjury that all the statements above are true and correct.
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_______________________________ Date Signed |
____________________________________ Signature of Class Member (or Authorized Guardian or Representative) |
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