This Claim Form exists in connection with the Scola v. Facebook, Inc. Settlement. You should complete this form if you wish to make a claim for money to pay for medical treatment for certain conditions and, if you have one of the allowable conditions, for damages. To receive payment from the Settlement Fund, you must complete this Claim Form. Claim Forms must be submitted no later than Monday, March 14, 2022. If you fail to submit a timely Claim Form, your Claim may be rejected, and you may be precluded from any recovery from the Settlement Fund.
Before you complete this Claim Form, you should read and be familiar with the Notice of Proposed Class Action Settlement (the “Notice”) available here.
The information on this form will be kept confidential and will not be shared with anyone at Facebook or its vendors.
A signed Diagnosis Verification Form attesting that your medical provider is a qualified medical provider, attesting that you meet the criteria for a Qualifying Diagnosis resulting in whole or in part from your work as a Content Moderator for Facebook, and identifying your diagnosis or diagnoses is required for a valid claim. Documentation should also be included with this form supporting your Claim for Other Damages (if applicable). Documents should be clear, readable copies, as anything you submit will not be returned to you. If you are filing online, please have this information ready before you start to file, as your Claim will not be saved if you have to come back and finish at a later time. Each file must be less than 20 MB and in one of the following formats: jpg, jpeg, png, gif, tif, tiff, doc, docx, xls, xlsx, pdf, txt, rtf, or zip.
Example documentation for Other Damages may include a personal declaration, supporting statements from others, receipts, credit card statements, bills, doctor’s notes, or other similar materials. Any declarations or statements must include at the end of the statement the following sentence: “I declare under penalty of perjury under the laws of the state of California that the foregoing is true and correct” and be signed and dated by the person making the statement.
Please Note: Documentation is not required at the time of claim filing. However, all documentation must be provided to the Settlement Administrator no later than Monday, March 14, 2022. If you do not upload any documentation during your online claim form, or if you want to submit additional documentation, please click here.
Remember, all claims must be submitted online, emailed, or postmarked no later than Monday, March 14, 2022.