December 9, 2017

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Yes, I am a victim of the Uber databreach and cover up of this fraud and I am therefore entitled to this claim and
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Furthermore, I hereby declare to have read and understood these general terms and conditions and accept them.

I also authorize Corpocon Legal B.V. / Uber databreach Claim to handle the assignment for and on behalf of myself in accordance with the power of attorney and, if necessary, take legal actions against Uber on my behalf.