THIS IS PAGE 1 OF 14 PLEASE READ ALL PAGES EXHIBIT C IN RE: CANADIAN PREPULSID RESOLUTION PROGRAM CLAIM FORM: CATEGORY OF CLAIM:

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1 THIS IS PAGE 1 OF 14 PLEASE READ ALL PAGES EXHIBIT C IN RE: CANADIAN PREPULSID RESOLUTION PROGRAM CLAIM FORM: CATEGORY OF CLAIM: YOU MUST CHECK OFF ONLY ONE BOX BELOW FOR THE CATEGORY OF CLAIM YOU ARE MAKING: TIER I: WRONGFUL DEATH TIER II: NON-FATAL CARDIAC ARREST OR TIER III: PRIMARY TACHYCARDIC VENTRICULAR ARRHYTHMIA Please read the Agreement and Instructions on the following pages and fully complete the Claim Form that follows. DEADLINE TO SUBMIT ALL CLAIM DOCUMENTATION: POSTMARKED ON OR BEFORE.

2 THIS IS PAGE 2 OF 14 PLEASE READ ALL PAGES AGREEMENT AND INSTRUCTIONS A. This form is to be used for submitting alleged wrongful death and personal injury claims by or on behalf of any Prepulsid Class Member. B. Please read this Claim Form in its entirety and answer all inquiries on the Claim Form itself (add additional sheets if necessary) and then sign and date the Claim Form. C. It is recognized that there may be conditions which prevent you from providing all the information sought in this Claim Form and all the required medical records. However, your diligence in providing this information and your medical records is required. The Medical Panel has the discretion to approve or deny your claim based on the information that you submit. D. Serve (1) the completed and dated Claim Form, (2), your medical records (see Section 6 of the Claim Form for a description of the medical records requirements) and, (3) the signed and dated Certificate of Service of Claim Form (with the appropriate box checked) attached to this Claim Form, to the Administrator's Office at the following address: Crawford Class Action Services Suite 3-505, 133 Weber Street North Waterloo, ON N2J 3G9 Toll free: E. This Claim Form and the medical records must be submitted (as proven by either the post-mark date (if standard lettermail service is used) or the submission date reflected on the receipt where registered mail, courier or other similar delivery method is used) no later than. Failure to submit this information by this deadline will result in your claim being dismissed with prejudice and prevent you from pursing any other Prepulsid -related claim. F. Within 60 days of submission of your medical records, the Parties may simultaneously submit to the Medical Panel confidential memoranda explaining the Parties' contentions as to your eligibility or non-eligibility under the Program and the category under which the claim is submitted. This memorandum is not to exceed five pages; exhibits to the memorandum may be abstracts or full documents not to exceed thirty pages. No expert reports or affidavits shall be submitted. G. Before any award may be paid under this Program, the full names, relationship to the alleged Prepulsid user, date of birth and address of all persons entitled to make a claim (including but not limited to claims pursuant to the Family Law Act or similar provincial or territorial legislation in effect throughout Canada) or share in the award must be provided in Section 2.a of the attached Claim Form. To the extent

3 THIS IS PAGE 3 OF 14 PLEASE READ ALL PAGES Claimants are persons representing minor or incompetent statutory or wrongful death heirs, such persons must represent and warrant that they have been appointed by court order as the proper representative and provide proof of such appointment or shall take necessary steps to obtain such appointment and approval thereof. Additionally, all such persons or statutory heirs must comply with all provisions of the Settlement Agreement. If your properly approved representative is required to obtain court approval of any award, the amount of such award shall be maintained in the strictest confidence and all papers shall be filed under seal and all hearings held in private to the extent allowable under the applicable law in Quebec and Ontario. Drafts of all such court papers must be approved by the Defendants before filing with the court. H. Should you have obtained a settlement with an entity other than Johnson & Johnson Corporation, Johnson & Johnson Medical Products Inc./Produits Medicaux Johnson & Johnson Inc., Janssen-Ortho Inc. or their related defendants in connection in any way with your ingestion of Prepulsid, you must so inform Defendants and advise the Administrator of the amount of any such settlement. I. You acknowledge that the decisions of the Medical Panel and Adjudicator may be ones with which you disagree, but further acknowledge that this eventuality is part of the Program, and you accept that eventuality by having filed a claim and understand that these decisions of the Medical Panel and Adjudicator are final and not subject to appeal. J. It is acknowledged that, by advancing claims for resolution through this Program, you thereby surrendered your rights to litigate your case and any other claims and potential claims relating in any way to Prepulsid, including but not limited to all claims, liabilities, demands, actions, suits and causes of actions for damages (including but not limited to current and future causes of action for survivorship or wrongful death, and current and future causes of action for personal injury and loss of consortium, recovery of economic loss, health care expenses, and purchase price), restitution, disgorgement, unjust enrichment, civil penalties, statutory penalties, injunctive and/or declaratory relief, whether class, individual, representative or otherwise in nature, including costs, expenses, penalties, and attorneys' fees, known or unknown, suspected or unsuspected, in law or equity, that accrued prior to the Opt-Out deadline that you, your spouse or other family member ever had, now have or hereafter can, shall or may have, which has been asserted or could have been asserted in any other action, and you acknowledge that in consideration for not opting out, and other good and valuable consideration, you have surrendered, unconditionally, and fully and forever released and discharged whatever rights or claims or potential claims you and your heirs or decedent's heirs and representatives may have had, or may ever have, against defendants Johnson & Johnson Corporation, Johnson & Johnson Medical Products Inc./Produits Medicaux Johnson & Johnson Inc., Janssen-Ortho Inc., all health care professionals, health care providers, health care facilities, pharmacies and other distributors of Prepulsid, and their parents and subsidiaries, affiliates, agents, lawyers, servants, employees, officers and directors and those who may have acted in concert with them, together with their respective insurers relating to your or the decedent's alleged ingestion of Prepulsid. You

4 THIS IS PAGE 4 OF 14 PLEASE READ ALL PAGES also acknowledge that when you decided not to opt out, you were authorized to release the aforementioned claims on behalf of yourself, your heirs and/or decedent s heirs, beneficiaries and representatives, and you specifically agree and undertake to indemnify and save defendants Johnson & Johnson Corporation, Johnson & Johnson Medical Products Inc./Produits Medicaux Johnson & Johnson Inc., Janssen-Ortho Inc. harmless from and against any such claims that may be brought by your spouse or other family member, with such indemnification and hold harmless agreement to include the payment of all reasonable costs and expenses of investigation, defense, settlement, legal fees, judgments, court costs and all other costs and expenses of defending any such claims. K. The signatories to the Claim Form, the law firms with which they are affiliated (if any) and the Claimants identified herein specifically agree to maintain the confidentiality of any awards of compensation that might result from the Program.

5 THIS IS PAGE 5 OF 14 PLEASE READ ALL PAGES CLAIM FORM FOR TIERS I, II AND III ANSWER ALL OF THE FOLLOWING QUESTIONS ON THIS FORM AND, AS NECESSARY, ATTACH ADDITIONAL SHEETS (Please use blue or black pen): 1. Information re: Alleged Prepulsid User: a. Current name and other names (e.g., maiden names, married names) used by the alleged Prepulsid user for the ten years prior to the alleged Prepulsid user s alleged adverse event through 60 days prior to service of this Claim Form (last name first, followed by first name and middle initial): Last First Middle Initial b. Alleged Prepulsid User s Current or last known Residence Address: Street Address City Province /Territory Postal Code ( ) ( ) Daytime Phone Number Evening Phone Number address c. Alleged Prepulsid User s date of birth : (Day/Month/Year) 2. Information for all other Claimants Submitting this Claim related to the above-listed alleged Prepulsid user [attach separate sheet(s) as necessary to answer all of the following questions for each such Claimant]: a. Current name and other names used by each Claimant and the nature of their relationship to the Alleged Prepulsid User listed above: Last First Middle Initial Nature of relationship to Alleged Prepulsid User (i.e. spouse, child, parent, etc.) Date of Birth (Day/Month/Year)

6 THIS IS PAGE 6 OF 14 PLEASE READ ALL PAGES Street Address City Province /Territory Postal Code ( ) ( ) Daytime Phone Number Evening Phone Number address b. If applicable, please provide details about the Claimant s relationship to the Alleged Prepulsid User (e.g., whether Claimant is the representative of an Alleged Prepulsid User who was/is a minor, etc.) and if the Claimant is a court-appointed representative, please attach copies of the court orders making such appointment: c. Claimant s Current Residence Address: Street Address City Province/Territory Postal Code d. Claimant/s date of birth: (Day/Month/Year) 3. Alleged Prepulsid User s Alleged Ingestion of Prepulsid : a. Date(s) ingested: b. Dosage(s) ingested (amount (e.g., 20mg.) and number daily): / /

7 THIS IS PAGE 7 OF 14 PLEASE READ ALL PAGES c. Ordering Physician(s) Name(s), Addresses and Phone Numbers: d. Pharmacies where all Prepulsid Prescriptions were ever filled (names, addresses and phone numbers of all such pharmacies): 4. Other Medications Used by Alleged Prepulsid User: a. For each prescription medication ingested by the alleged Prepulsid user during the three years prior to the alleged adverse event through 60 days before service of this Claim Form (or if the alleged user was under age 12 at the time of the adverse event, during the alleged user s entire life through 60 days before service of this Claim Form), please provide the following information (attach additional sheets, if necessary): Name of drug and where purchased Date(s) ingested Ordering MD, if one

8 THIS IS PAGE 8 OF 14 PLEASE READ ALL PAGES b. For each over-the-counter medication ( OTC ) ingested by the alleged Prepulsid user during the three months prior to the alleged adverse event, please provide the following information (attach additional sheets, if necessary): Name of drug and where purchased Date(s) ingested Ordering MD, if one 5. Alleged Adverse Event: a. Date of Alleged Adverse Event: (Day/Month/Year) b. Description of Alleged Adverse Event:

9 THIS IS PAGE 9 OF 14 PLEASE READ ALL PAGES 6. Medical Records Requirements: a. The following records of the Alleged Prepulsid User must be submitted with this Claim Form. In the case of an Alleged Prepulsid User who was under 12 years of age at the time of the alleged Prepulsid ingestion, the time frame for the referenced records is from prenatal care and birth through to the date of death or until 60 days before the time the claim is submitted under the Program, whichever is applicable: (1) For the five-year period preceding first Prepulsid ingestion through to the date of death or until 60 days before the claim is submitted under the Program, whichever is applicable : (a) (b) (c) (d) Full records for hospitalizations and emergency room care; Complete physician records from the person s primary care physician or physicians or pediatrician if applicable; Complete physician records from all treating internists, cardiologists, and pulmonologists; and All cardiac testing and monitoring records. (2) For the three-year period preceding first Prepulsid ingestion through to the date of death or until 60 days before the claim is submitted under the Program, whichever is applicable: (a) (b) Full records for gastroenterology care of any kind; and Prescription records for all prescribed medications. (3) For the one-year period preceding first Prepulsid ingestion through to the date of death or until 60 days before the claim is submitted under the Program, whichever is applicable: (a) Full records for any kind of medical care in the 1 year preceding first Prepulsid ingestion not otherwise required by section 6.a(1) or (2) above (doctor, hospital, pharmacy, ambulance, therapy, etc.)

10 THIS IS PAGE 10 OF 14 PLEASE READ ALL PAGES b. Please provide the name, address, telephone number, medical specialty of any medical professional who provided you with treatment (and who has not been listed in 6.a above), starting 5 years prior to the date of alleged Prepulsid use, through to the date of death or until 60 days before the time the claim is submitted under the Program whichever is applicable. Please note that you do not need to obtain or submit records from the medical professionals listed in the space below in connection with completing this Claim Form, although the Parties may seek to obtain such records, upon a showing of good cause to the Administrator. 7. Economic Losses: List all economic losses you are claiming, including but not limited to lost wages, and in the event you are claiming economic loss in the form of lost wages, provide the name and address of the Alleged Prepulsid User s employer, title at his or her place of employment and the dates of employment you claim were lost due to Prepulsid use:

11 THIS IS PAGE 11 OF 14 PLEASE READ ALL PAGES 8. Prepulsid -Related Settlements With Other Third Parties: a. Has the Alleged Prepulsid User reached a settlement with any other party besides one of the Janssen or Johnson & Johnson defendants, e.g., including but not limited to with a doctor, hospital, pharmacy, or insurer? YES NO b. If you answered yes to question 8.a. above, identify the name of the person and/or entity with whom the settlement was reached, the amount of the settlement, whether the settlement funds have been received and whether a release has been signed: 9. Pendency of Prepulsid Lawsuits and/or Claims: a. Is the Alleged Prepulsid User involved in any pending Prepulsid related lawsuit or claim other than the one for which you are submitting this Claim Form? YES NO b. If you answered yes to question 9.a. above, describe the name of, venue of, docket number (if a filed lawsuit) and parties to the lawsuit(s) and/or claim(s):

12 THIS IS PAGE 12 OF 14 PLEASE READ ALL PAGES PLEASE ENSURE THAT YOU SIGN AND DATE THIS FORM (BELOW) AND THAT YOU COMPLETE, SIGN AND DATE THE CERTIFICATE OF SERVICE OF CLAIM FORM. YOUR CLAIM WILL NOT BE PROCESSED WITHOUT THIS CERTIFICATE. Dated: [Plaintiff s/claimant s Signature] Printed Name of Plaintiff/Claimant Printed Residence Address Dated: [Signature of Plaintiff s/claimant s Attorney (if any) Printed Individual Attorney Name Law Firm Name, Address, Telephone/Fax

13 THIS IS PAGE 13 OF 14 PLEASE READ ALL PAGES CERTIFICATE OF SERVICE OF CLAIM FORM I,, declare that: (insert name) I am at least 18 years of age. My address is: Street Address City Prov Postal Code My telephone number is: ( ) On Date, I caused to be served the following document(s): CLAIM FORM(S) FOR THE CLAIM(S) OF: (insert name(s) of all Claimants whose form(s) are being served with this certificate) by enclosing the originals of said document(s) in (an) envelope(s) and delivering said envelope(s) to the Administrator at the following address: in the following manner: Crawford Class Action Services Suite 3-505, 133 Weber Street North Waterloo, ON N2J 3G9 Toll free: BY MAIL: I know that the envelope was sealed, addressed to the Administrator, with postage thereon fully prepaid, and placed for collection and mailing on this date, with Canada Post at: City Province ; or BY PERSONAL SERVICE: I caused the envelope(s) to be delivered by a messenger service by hand to the Administrator; or

14 THIS IS PAGE 14 OF 14 PLEASE READ ALL PAGES BY OVERNIGHT DELIVERY: I enclosed the envelope(s) in an overnight courier envelope addressed to the Administrator and deposited same with the overnight courier company. I declare under penalty of perjury under the laws of the Province of that the above is true and correct. (province of residence) Executed on, at Date City Province Name