BERJAC SETTLEMENT CLAIM FORM

Transcription

1 Circuit Court of the State of Oregon for Multnomah County Must be Postmarked No Later than December 12, 2016 BERJAC SETTLEMENT CLAIM FORM You must complete this claim form and submit it by December 12, 2016 to be eligible to share in the settlement. Table of Contents 1. Personal Information Am I an eligible Class member? If you received a calculation along with this claim form If you disagree, in whole or in part, with the calculations you received, or you did not receive a calculation Release and Reduction of Claims Signature Checklist Calculation..11 1

2 1. Personal Information Last Name(s) First Name(s) and Middle Initial(s) Company or Other Entity (if claimant is not an individual) and Contact Person Mailing Address City State Zip Code Telephone Number (Day) Address (if you provide an address, you authorize the Claims Administrator to use it to contact you and to provide you with information) Identity of Claimant (check one box only) Individual Joint Owners Estate Corporation LLC Trust Partnership Private Pension Plan Legal Representative IRA, Keogh, or other type of individual retirement plan (indicate type, mailing address, and name of current custodian) Other (describe) 2

3 2. Am I an eligible Class member? Read the following statements and check the appropriate box. If statement a. is false, or if any one of statements d. through f. or h. is true, then you are not an eligible Class Member and you do not have a claim in this settlement. a. I purchased, or received a transfer of, an investment in Berjac of Oregon or Berjac of Portland. b. I have not been repaid the money owed to me by Berjac with respect to my investment. c. I was repaid the money owed by Berjac with respect to my investment, but subsequently I paid the Trustee in the Berjac bankruptcy on a preference claim for money received from Berjac. d. I am a Defendant in the class action lawsuit. e. I am Michael Holcomb, Nancy Holcomb, Gary Holcomb, Betty Holcomb, Jennifer Chalmers, Kristin Van Breeman, or Grant Holcomb. f. I transferred my interest with respect to the class action lawsuit. g. I am the successor-in-interest of a person who transferred their interest with respect to the class action lawsuit. (If statement g. is true, state the name(s) and account number(s) of the person who transferred their interest:. Attach copies of documents transferring the interest.) h. I excluded myself from the settlement by sending a letter see Question 13 of the Class Notice. 3. If you received a calculation along with this claim form If you received in Part 8 of this claim form one or more calculations of the amounts of money you or your predecessor-in-interest was owed by Berjac on August 31, 2012, the amount of money you or your predecessor-in-interest paid to the Trustee in the Berjac bankruptcy on a preference claim, and the amount of your Net Recognized Loss, examine the calculations. If you agree with the calculations, check the appropriate box on the calculations, sign the calculations, 3

4 and proceed to Part 5 of this claim form. If your Net Recognized Loss is zero or less, you do not have a claim in this settlement. If you do not agree with the calculations, check the appropriate box on the calculations, and proceed to Part 4 of this claim form. If you agree in part, and disagree in part, with the calculations, check the appropriate box on the calculations, cross out any parts of the calculations you disagree with, and sign the calculations. You should proceed to Part 4 of this claim form, and enter any corrected or additional information called for. 4. If you disagree, in whole or in part, with the calculations you received, or you did not receive a calculation If you did not receive a calculation in Part 8, or you do not agree with the calculations in Part 8, in whole or in part, then you must document as best you can the amounts of money you believe you or your predecessor-in-interest was owed by Berjac on August 31, 2012 and the amount of money you or your predecessor-in-interest paid to the Trustee in the Berjac bankruptcy on a preference claim (if any). In addition, you must document as best you can the amounts of distributions you or your predecessor-in-interest has received from the Berjac and the Michael and Gary Holcomb bankruptcies, the amounts of money that you or your predecessor-in-interest received in settlement with a third party (e.g., an adviser), and any amount you or your predecessor-in-interest received for the purchase of your claim in bankruptcy (if sold). Go through your personal records and find documents that you believe prove these amounts. You may find information in canceled checks (front and back), promissory notes, account statements, distribution statements, settlement agreements, and purchase agreements. Fill out the following forms. If the correct answer is None, please write None. If you agree in part, and disagree in part, with the calculations, then you only need to fill in any corrections and any additional information. a. Amounts of money owed by Berjac on August 31, 2012 Amount of money Account No. 4

5 Total amount of money owed If you need additional space to list the amounts owed, make photocopies of this page. b. Amount of distributions received from the Trustees in the Berjac bankruptcy and the Michael and Gary Holcomb bankruptcies Amount of distribution Date received Total Amount of distributions received If you need additional space to list the amounts paid, make photocopies of this page. c. Amount of money paid to the Trustee in the Berjac bankruptcy on a preference claim Amount Paid Date paid Total Amount paid If you need additional space to list the amounts paid, make photocopies of this page. d. Amounts of money received in settlement from any other person (e.g., an adviser) Amount of money received in settlement Date received 5

6 Total amount of money received in settlement If you need additional space to list the amounts received, make photocopies of this page. e. Amounts of money you received to purchase your claim in bankruptcy (if sold) Amount of money received to purchase bankruptcy claim Date received Total amount of money received to purchase claim If you need additional space to list the amounts received, make photocopies of this page. f. Calculating your Net Recognized Loss Amounts of money owed by Berjac on August 31, 2012 (from above): Subtract amount of distributions received from the Trustees in the Berjac and Holcomb bankruptcies (from above) Add amount of money paid to the Trustee in the Berjac bankruptcy on a preference claim (from above): Subtract amount of money received in a settlement (from above): Subtract amount of money received to purchase bankruptcy claim (from above): + Your Net Recognized Loss = If your Net Recognized Loss is zero or less, you do not have a claim in this settlement. You must attach to your claim form the documents that you believe prove any of the amounts you entered above. If you are relying on the calculations, you do not need to attach the documents. In all cases, you must attach any documents that evidence the transfer of an interest with respect to the class action. 6

7 You should now proceed to Part 5 of this claim form. 5. Release and Reduction of Claims I/We request payment from the settlement fund, and I/we agree to the terms set out below: Release of Umpqua Bank I/we (including my respective representatives, attorneys, agents, assigns, heirs, or successors) release and forever discharge Umpqua Bank (for itself and as successor to Centennial Bank), Umpqua Holdings Corporation, their respective parent corporations, and their respective subsidiary corporations (including their respective current or former directors, officers, employees, representatives, attorneys, insurers, assigns, heirs, and successors) (collectively, the Umpqua Released Persons ) from any and all claims, actions, suits, demands, liens, judgments and liability whatsoever, whether known or unknown or discovered or undiscovered, arising from or relating to (i) any claim, cause of action, demand, or allegation asserted or attempted to be asserted by Plaintiffs, or any of them, in connection with Cox v. HFLP; (ii) the Berjac of Oregon and/or Berjac of Portland banking relationships with Umpqua Released Persons; or (iii) any conduct, actions, transactions, or occurrences set forth or attempted to be set forth in any complaint filed by Plaintiffs in Cox v. HFLP. Release of Pacific Continental Bank I/we (including my respective representatives, attorneys, agents, assigns, heirs, or successors) release and forever discharge Pacific Continental Bank, Pacific Holding Corporation, Century Bank, their respective parent corporations, and their respective subsidiary corporations (including their respective current or former directors, officers, employees, representatives, attorneys, insurers, assigns, heirs, and successors) (collectively, the PCB Released Persons ) from any and all claims, actions, suits, demands, liens, judgments and liability whatsoever, whether known or unknown or discovered or undiscovered, arising from or relating to (i) any claim, cause of action, demand, or allegation asserted or that could have been asserted by Plaintiffs, or any of them, in connection with Cox v. HFLP; or (ii) any conduct, actions, transactions, or occurrences set forth or that could have been set forth in any complaint filed by Plaintiffs in Cox v. HFLP. Covenant not to execute with respect to Jones & Roth and Release of Persons Associated with Jones & Roth I/we (including my successors, assignees, and agents) covenant and agree not to execute against Jones & Roth, and any of its subsidiaries or affiliated entities and each of their respective current and former officers, directors, employees, representatives, attorneys, assigns, heirs, predecessors and successors (the Jones & Roth Parties ) with respect to 7

8 the $3.5 million Stipulated Judgement in Cox v. HFLP, except to the extent of any professional liability insurance coverage provided to Jones & Roth by CAMICO. I/we (including my successors, assignees, and agents) also covenant and agree not to execute against XL, and any of its subsidiaries or affiliated entities, successors, predecessors or assigns (the XL Parties ), with respect to the $3.5 million Stipulated Judgement in Cox v. HFLP. In particular, I/we (including my successors, assignees, and agents) may execute, other than against the Jones & Roth Parties and the XL Parties, upon all amounts covered by any professional liability insurance provided to Jones & Roth by CAMICO, including upon all amounts owed by CAMICO as a consequence of its indemnity obligations arising out of any professional liability insurance provided to Jones & Roth by CAMICO. ORS I/we (including my successors, assignees, and agents) will attempt to recover and collect the Stipulated Judgment solely and exclusively from CAMICO and/or its agents, brokers, employees, and officers. I/we (including my successors, assignees, and agents) agree that all such efforts undertaken pursuant to this paragraph will be undertaken solely at their own risk and expense and that if those efforts are in any way unsuccessful, the Plaintiffs and all members of the Settlement Class will have no recourse against the Jones & Roth Parties and/or their attorneys and/or against the XL Parties. I/we (including my successors, assignees, and agents) release and forever discharge (i) the current and former officers, directors, partners, employees, and agents of Jones & Roth and (ii) the XL Parties from any and all claims, actions, suits, demands, liens, judgments, and liability whatsoever, whether known, unknown, or undiscovered, arising from or relating to (i) the purchase of Berjac Securities; (ii) the claims that were the subject matter of Cox v. HFLP; and (iii) the facts or circumstances relating to or otherwise giving rise to the claims that were the subject matter of Cox v. HFLP. Release of Fred W. Holcomb I/we (including my respective representatives, attorneys, agents, assigns, heirs, or successors) release and forever discharge Fred W. Holcomb (including the Fred Holcomb Survivor s Trust and Betty Holcomb Family Trust created under instrument dated June 4, 2000)) from any and all claims, actions, suits, demands, liens, judgments and liability whatsoever, whether known or unknown or discovered or undiscovered, arising from or relating to (i) any claim, cause of action, demand, or allegation asserted or attempted to be asserted by Plaintiffs, or any of them, in connection with Cox v. HFLP; or (ii) any conduct, actions, transactions, or occurrences set forth or attempted to be set forth in any complaint filed by Plaintiffs in Cox v. HFLP. Reduction of Claims I/we (including my respective representatives, attorneys, agents, assigns, heirs, or successors) agree that any payment or distribution made from the class action settlement fund to me shall reduce, on a dollar-for-dollar basis, the amount of my claims against any non-party to this settlement that arises from or relates to any interests in a Berjac security. 8

9 6. Signature I (We) hereby declare that the above statements provided in this Claim form are true to the best of my/our knowledge and belief, and that I/we understand it is made for use as evidence in court and is subject to penalty for perjury. I agree to the Release, Covenant Not to Execute, and Reduction of Claim terms in this Claim Form. Signature of Claimant Date Signature of Joint Claimant (if any) Date Print Name Print Name If the Claimant is other than an individual, or is not the person completing this form, the following also must be provided: Signature of person signing on behalf of Claimant Print Name Date Capacity of person signing on behalf of claimant, if other than individual; e.g., personal representative, manager, corporate officer, custodian, etc. 7. Checklist 1. Please make sure to sign the Signature Section of the Proof of Claim form. 2. If this claim form is being made on behalf of Joint Claimants, then both must sign. 3. If you received one or more calculations in Part 8, please make sure you checked the appropriate box on the calculations and signed the calculations. 4. Remember to attach supporting documentation called for in this claim form. 5. For an overview of what constitutes adequate supporting documentation, please visit 6. DO NOT SEND ORIGINALS OF ANY SUPPORTING DOCUMENTS. 7. Keep a copy of your claim form and all documentation submitted for your records. 8. The Claims Administrator will acknowledge receipt of your Proof of Claim by mail or by (if you provide an address) within 30 days. Your claim is not deemed filed until you receive an acknowledgement. If you do not receive an acknowledgement within 30 days, please call the Claims Administrator at (503) If you move, please send your new address to the Claims Administrator at the address below. 9

10 10. Do not use highlighter on the claim form or supporting documentation. This claim form must be postmarked no later than December 12, 2016 and must be mailed to: Berjac Settlement Claim c/o Transeth & Associates, LLC 215 S.W. Washington Street, Suite 204 Portland, Oregon