CL AIM FORM INSTRUC TIONS

IN THE CIRCUIT COURT OF ST. LOUIS COUNTY

Laura Unverferth et al., on behalf of themselves
and all others similarly situated,
v.

Plaintiffs,

AMERICAN TRAFFIC SOLUTIONS, INC.

et al.,

Cause No. 11SL-CC03363-01

Consolidated Actions

Defendants.

This Official Proof of Claim Form (Proof of Claim) has been provided to you in connection with the Settlement of this class action
litigation (Settlement). By properly filling out this Proof of Claim and certifying your eligibility as a settlement class member
(Settlement Class Member) to participate in this Settlement, you may be entitled to receive a monetary payment, subject to
the approval of your claim in accordance with the settlement documents.
Your fully-completed Proof of Claim and any necessary supporting documentation must be postmarked or submitted
online at the Settlement Website by February 28, 2015. Any failure by you to timely submit a fully-completed Proof
of Claim, and, if appropriate, any required supporting documentation, may result in the denial of your claim.
PART I. ELIGIBILITY
If you received a notice of violation (Notice of Violation) of a Municipal red light camera ordinance issued by or on behalf of a
Missouri Municipality that contracted with American Traffic Solutions, Inc. or American Traffic Solutions LLC, and which occurred
on or before November 21, 2014, and you paid the fine, in whole or in part, assessed for such violation, you may be eligible to
receive money pursuant to this Settlement.
Excluded from the Settlement Class are: (1) defendants, their officers, directors, elected officials, and appointed
officials; (2) any and all Persons who timely and validly request exclusion from the Settlement Class; (3) the named
plaintiffs in Sarah Tupper and Sandra Thurmond v. The City of St. Louis et al., Case No. 1322-CC10008 in the Circuit
Court of the City of St. Louis; and (4) anyone who was issued a Notice of Violation by the City of St. Louis for violation
of its red light camera ordinance on or after February 11, 2014 and made payment, in whole or in part, of the fine
assessed for such violation.
PART II. HOW TO PREPARE YOUR CLAIM
1. In order to be eligible to receive any payment as part of this Settlement, you must have received, either as an operator or
registered owner of a vehicle, a Notice of Violation of a Municipal red light camera ordinance for a violation which occurred
before November 21, 2014. The Notice of Violation must have been issued pursuant to a Municipal red light camera ordinance
by or on behalf of one of the following twenty-seven Missouri municipalities: (1) Arnold, (2) Bellerive Acres, (3) Bel-Nor, (4)
Beverly Hills, (5) Brentwood, (6) Bridgeton, (7) Calverton Park, (8) Clayton, (9) Country Club Hills, (10) Creve Coeur, (11)
Dellwood, (12) Ellisville, (13) Excelsior Springs, (14) Ferguson, (15) Florissant, (16) Grandview, (17) Hazelwood, (18) Kansas City,
(19) Moline Acres, (20) Northwoods, (21) Richmond Heights, (22) St. Ann, (23) St. John, (24) St. Joseph, (25) the City of St.
Louis, (26) Sugar Creek, or (27) Washington. In addition, you must have paid, in whole or in part, the fine assessed for such
violation. In other words, you must have been the person to whom the Notice of Violation was issued, and the fine must have
been paid personally by you and not someone else, such as a joint registered owner, family member, or friend.
If you are not a person who:
(a) received a Notice of Violation alleging a violation of a Municipal red light camera ordinance violation that
occurred on or before November 21, 2014, in one of the above named Municipalities; and
(b) paid all or part of the fine assessed for such violation, then you are not eligible to receive payment as part of
this Settlement and should NOT submit a Proof of Claim.
2. In order to be eligible to participate in the distribution of the Settlement funds, you must properly complete, sign, and mail (or
submit online at the Settlement Website) this Proof of Claim to the Claims Administrator prior to February 28, 2015. Proofs
of Claim postmarked (or submitted online) after February 28, 2015, will not be honored. You will not be able to receive a
payment if your Proof of Claim is submitted via the Claims Administrators website or postmarked after February

28, 2015, but you will still be bound by all of the other terms of the Settlement and any orders of the Court. If you
do nothing, you forfeit the opportunity to receive any monetary compensation and you give up any rights to sue
Defendants, and certain parties related to them, separately about the claims that have been or could have been
asserted in these lawsuits.
3. If you received and paid a fine for more than one Notice of Violation of a Municipal red light camera ordinance, you must
submit a separate Proof of Claim for each such Notice of Violation. For example, if you received and paid a Notice of Violation
on January 1, 2010, and then received and paid a separate Notice of Violation on February 1, 2010, you must submit a
separate Proof of Claim for each Notice of Violation. If you have already received a refund from the Municipality for a
fine you paid in response to a notice of violation of a given Municipal red light camera ordinance, do not submit
a Proof of Claim with respect to that Notice of Violation.
4. The submission of this Proof of Claim does not ensure that your claim will be upheld or that you will share in the Settlement.
All claims are subject to verification and investigation as provided in the settlement documents filed with the Court.
5. Executors, administrators, guardians, conservators, and trustees may complete and sign the Proof of Claim on behalf of
persons or entities represented by them, but they must identify such persons or entities and provide proof of their authority
(e.g., powers of attorney or currently effective letters testamentary or letters of administration) to do so.
6. Important additional information regarding the Settlement and this Proof of Claim is contained in the notice (Notice)
available at www.MORLCEnforcement.com or by calling the Claims Administrator toll free at 1 (866) 681-9151 or writing the
Claims Administrator at P.O. Box 1994, Faribault, MN 55021-6190. The Notice is a summary and does not describe all of the
details of the Settlement, which has been memorialized in a Settlement Agreement executed by the parties to the Settlement
and filed with the Court. For full details of the matters discussed in the Notice, you may review the Settlement Agreement,
with exhibits, and the Long Form Notice by visiting www.MORLCEnforcement.com.
7. If you have any questions or need additional Proofs of Claim, please go to www.MORLCEnforcement.com or contact the
Claims Administrator by calling the Claims Administrator toll free at 1 (866) 681-9151 or writing the Claims Administrator at
P.O. Box 1994, Faribault, MN 55021-6190. You may make photocopies of this form.
8. If you think that you meet the criteria set forth above and wish to apply for possible payment, for each separate claim you
must do the following:
a. Read this Proof of Claim Form.
b. Review the Notice which explains in more detail who is entitled to a payment. If you do not have the Notice, or have
questions, contact the Claims Administrator.
c. Complete and submit a Proof of Claim online through the Settlement Website: www.MORLCEnforcement.com OR fully
complete the Proof of Claim by filling in all of the required information, sign , and return it by mail along with any
additional documents you deem necessary, postmarked on or before February 28, 2015 to the Claims Administrator,
addressed as follows:
Claim Administrator
P.O. Box 1994
Faribault, MN 55021-6190

F O R O F F I C I A L U S E O N LY

REQUIRED

03

Write in the 10 digit number (beginning with 000) that is located under the
bar code on the front of the notice postcard you received in the mail.
If you did not receive a notice postcard, leave this section blank.

Page 1 of 2

OFFICIAL PROOF OF CL AIM FORM

PART III. CLAIMANT IDENTIFICATION
Please type or print

Name

Notice Number on Notice of Violation (if available)

/
/
Date of Violation (if known)

Were you the registered owner of the motor vehicle identified in the Notice of
Violation at the time the Notice of Violation was issued?

YES

NO

Was the Notice of Violation issued to you as the operator of the motor vehicle
identified in the Notice of Violation?

YES

NO

At the time when you received the Notice of Violation, was the motor vehicle
identified in the Notice of Violation jointly registered with another person in
addition to you?

YES

NO

Did you personally pay the fine assessed for the violation of the Municipal red
light camera ordinance?

YES

NO

Have you already received a refund of the fine that you paid?

YES

NO

Are you an officer, director, or elected or appointed official of the Missouri

municipality where the alleged ordinance violation took place?

YES

NO

Additionally, to be eligible to receive money from the Settlement Fund you must be the person who both received the
Notice of Violation and paid the fine and you must supply the following information:

Street Address

County

Foreign Province
(
Area Code

)

Telephone Number (Day)

(
)

Facsimile Number

*4476*

*CFW*

State

Zip Code

Foreign Country
(
Area Code

Telephone Number (Night)

E-Mail Address

*RUST*

*0123456789*
PART IV. SUBMISSION TO JURISDICTION OF COURT
By submitting this Proof of Claim:
1. I hereby submit to the jurisdiction of the Circuit Court of St. Louis County, Missouri, and I agree to be bound by the terms of
the Settlement Agreement referred to in the Notice.
2. I hereby declare, certify, swear and affirm, under penalty of perjury, that the information I have provided in this Proof of
Claim and any supporting documentation is true and correct to the best of my knowledge, that either as an operator or
registered owner of a vehicle I received a Notice of Violation issued by or on behalf of a Municipality that alleged a violation
of a Municipal red light camera ordinance and which occurred on or before November 21, 2014, that I paid the fine, in whole
or in part, assessed for such violation, and that I qualify for membership in the Settlement Class, based on the eligibility
requirements described in Section I, above.

Signature of Claimant

Signature of Co-Claimants(s) (if any)

Page 2 of 2