DIPF Direct Purchaser Settlement

Claim Form

In order to prepare the Claim Form so that you can download and print it with the bar code needed for us to process it, please fill out the form below and click Submit. This is a large file and might take a few minutes.

Once your personalized Claim Form has been generated and you have printed it out, you must mail the completed form to the address listed on the printed Claim Form.

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