Submit a Claim

Claim Form

Claimant Information

Please provide contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form.

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone

Email

Benefit Selection

Please select the VIP Membership Card you wish to receive.*

VIP Membership Card for Rick's Cabaret in Chicago, IllinoisVIP Membership Card for Scarlett's Cabaret in Washington Park, Illinois

Attestation & Signature

By signing below, I affirm that I am a member of the Settlement Class, and that, under penalty of perjury, all information I provided in this Claim Form is true and correct to the best of my knowledge. I understand that the Settlement Administrator will review my Claim Form and that I may be required to submit additional documentation to validate my claim.

Signature

Date