Redacted Champlin Claims

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 4 of 56
1. Is your Subsistence Claim based on hunting

and/or fishing losses?
2. Do you ever hunt or fish for pleasure or sport?
D
D
Hunting
Yes
!RI
Fishing
l:&l
No
3. Are you a Commercial Fisherman or Seafood

l:&l Yes
D No
Crew?
4. List the species of Game or Seafood that you hunted and/or fished for subsistence use in the year
before the Spill, and identify the time periods or seasons throughout the year when you hunted
and/or fished each species.
Crab
5. Provide the quantity of each species of Game and/or Seafood you fished and/or hunted in each time
period or season during the year before the Spill, including the amount you consumed and the amount
you gave to your family for their personal consumption or for the purposes of barter.
500.00 Lbs.
6. Identify the specific family members (including you) who relied on each of the species of Game or
Seafood that you hunted and/or fished before the Spill. List each family member and provide a description
of his or her relationship to you (e.g., wife, mother, daughter, aunt). To the extent that your or your family's reliance
on certain species varies by time period or season, describe that variation below.
Ray Herron (Step-Father); Barry Herron (Brother); Matt Herron (Brother); Michael Herron (Brother); Sheena Herron
(Step-Sister); Horse Maise (Father-In-Law); Nola Maise (Mother-In-Law); Cheryl Creppel (Sister-In-Law)
7. Provide a specific description of where you hunted and/or fished for each species in the Gulf of Mexico
before the Spill. In addition to the written description below, also provide a map that identifies where
you hunted and/or fished each species in the Gulf of Mexico before the Spill.
Plaquemines Parish
10. Out of the total quantity of Game and/or Seafood you and your family relied on before the Spill,
approximately what percentage by species and location came from areas that were later closed,
impaired, or harmed because of the Spill?
100 %
Fish
s.
Provide the quantity of each species of Game and/or Seafood you fished and/or hunted in each time
100.00 Lbs.
CFlO
Y.1
TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORIZONSETTLEMENTS.COM

Plaquemines Parish
100 %
Shrimp
2000.00 Lbs.
Plaquemines Parish
100 %
CFlO
v. l
TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWAIERHORIZONSETILEMENTS.COM

Oyster
6.00 Sacks
Plaquemines Parish
100 %
CFlO
v.1
TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORJZONSETTLEMENTS.COM
8. Do you fish or hunt to ha1Vest, catch, barter,

consume, or trade Gulf of Mexico natural resources
(including Seafood and Game), in a traditional or
customary manner, to sustain your basic personal
or family dietary, economic security, shelter, tool,
or clothing needs?
[fil
Yes
No
If you checked "Yes" for Question 8, explain.

To provide groceries as a means of supplementing the dietary needs of both myself and my family.
9. Describe the equipment and methods you use to hunt and/or fish for subsistence use.
Trawl nets, vessel, traps.
CF10
v.1
TO FILE YOUR CLAIM ONLINE VISIT WWW. DEEPWATERHORIZONSITTLEMENTS.COM
11. Did you continue to fish and/or hunt for subsistence

purposes alferthe Spill?
Yes
IBl
No
If you checked "Yes," for Question 11, provide a specific description of where and what species you fished
and/or hunted for subsistence purposes between April 20, 2010 and December 31, 2011, and what
quantity of Game and/or Seafood you were able to catch over that period.
12. Did you stop fishing and/or hunting for subsistence

purposes in areas that where closed, impaired, or
harmed because of the Spill?
IBl
Yes
No
If you check "Yes," for Question 12, identify the area, and your best estimate of when those areas were
closed, and the dates you resumed fishing and/or hunting in those areas. If you are asserting that an
area was not closed but was impaired or harmed, also describe the impairment or harm. (Attach additional
sheets if you need more space.)
Fishing or Hunting Area
Plaquemines Parish
CFlO
v.1
Dates Closed or Impaired/Harmed
From _1_J_]J)_j 2010 to -1L)_J__J 2012

(Month/Day/Year)
(Month/Day/Year)
If not
basis of impairment:
Date You
Resumed Hunting
and/or Fishing
-1LJ_J__j
2012
(Month/Day/Year)
TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORIZONSETTLEMENTS.COM
1. If You Have Your Own Attorney. Unless you check the box below, the Claims Administrator will make any
payments jointly to you and to your attorney, which means that both you and your attorney will need to endorse the
check before a bank will honor it.
!:RI Check here if you want the Claims Administrator to make payments in connection with this and any other claim
you may file in the Deepwater Horizon Economic and Property Settlement only to your attorney. This means that
the Claims Administrator will send your payment to your attorney, who will then pay you pursuant to the retainer
agreement you have with him/her.
2. If You Do Not Have Your Own Attorney. If you have not retained an attorney to represent you in connection
with your Spill-related claim, the Claims Administrator will make any payments to which you are entitled directly to
you by check. Payment checks will be sent by First Class Mail to the address you provided in the Registration Form o
to the address that the Claims Administrator confirms for you during the processing of your Claim. You have an
obligation to notify the Claims Administrator if your address changes.

The Claims Administrator will report annually to federal and state taxing authorities, using a Form 1099 or state form
equivalent, for certain payments made. The Claims Administrator will send you a copy of that form, but cannot give
you any tax advice regarding any payment issued to you. You should consult with your own tax advisor to determine
the tax impact of any payment you receive from the Claims Administrator.
3. Garnishments, Liens and other Attachments. Legally authorized garnishments, liens, or similar forms of
attachments relating to your claim will be honored and deducted from your payment.
4. W-9 Form Requirement. All claimants must provide a W-9 Form. To obtain a copy of that form, go to
l I 1
r.! I t
"11"1
"'.
Ir.
<
I'. _ ;,,
oo
'
I certify and declare under penalty of perjury pursuant to 28 U.S.C. Section 1746 that the information provided in this
Claim Form is true and accurate to the best of my knowledge, and that supporting documents attached to or submitted in
connection with this form and the information contained therein are true, accurate, and complete to the best of my
knowledge, and I understand that false statements or claims made in connection with this Claim Form may result in fines,
imprisonment, and/or any other remedy available by law to the Federal Government, and that suspicious claims will be
forwarded to federal, state, and local law enforcement agencies for possible investigation and prosecution.
By submitting this Claim Form, I consent to the use and disclosure by the Claims Administrator and those assisting the
Claims Administrator of any information about me that they believe necessary and/or helpful to process my claim for
compensation and any payment resulting from that claim.
Signature:
/S/ Soren Gisleson
Date:
_Q_j_L_j 2012
(Month/Day/Year)
The claimant must sign this Claim Form personally. No one can sign on behalf of the claimant unless the claimant is
deceased, a Minor, or Incompetent. If the claimant is deceased, a Minor, or Incompetent, an authorized Representative
may sign.
CFIO
v.I
TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORIZONSITTLEMENTS.COM
6.
see Exhibit A
7.
see Exhibit A
8.
see Exhibit A
9.
see Exhibit A
Relationship: step-sister
Name: Horse Maise
Name: Nola Maise

Relationship: mother in law
Name: Cheryl Crepppel
Relationship: sister in law
Relationship:
Name:
11.
Relationship:
Name:
12.
Relationship:
c.
Male
Iii Female
Iii Male D
Relationship: father in law
Name:
10.
Name: Sheena Herron
25
Female
80
Male
Iii Female
77
Male
Iii Female
55
Male
Female
Male
Female
Male
Female
PERCENT OF WEEKLY PROTEIN SUPPUEO BY SUBSISTENCE Acn:vrrIES
You must state the total percent of weekly protein you consumed or supplied to each family member as a result of your
subsistence activities. For example, if the fish you caught provided half of the total protein a family member ate during
the week, then you would write or type 50% in the column labeled "Percent of Weekly Protein" for that family member.
Percent of Weekly
Protein
Claimant or Family Member Name
1.
Kim Champlain - 70%
2.
Ray Herron - 70%
3.
Barry Herron - 70%
4.
Matt Herron - 70%
5.
Michael Herron - 70%
6.
Sheena Herron - 70%
7.
Horse Maise - 70%
D.
NAME OF T:HE PERSON WHO COMpLETED THIS FORM
In the space below, print or type the date you completed this form, your name, and your relationship to the claimant
(e.g. self, attorney or CADA Team).
Date Completed:
__:!__:!__;
12
(Month/Day/Year)
Soren Gisleson
Name (Printed or Typed)
Attorney
Relationsh.!Q_ to Claimant
SUB-2
v.1
WWW.DEEPWATERHORIZONECONOMICSETTLEMENT.COM
Page 2 of 2

Claimant: Kim Champlin
Exhibit A: Species Detail
crab, shrimp, oyster, flounder, redflsh
Part 8. contd. Age and Gender Information

No.
13
14
15
16
17
18
19
No.
8
9
10
11
12
13
Species
Claimant or Family Member Name and

Name:
Gender
Age
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Part C. contd. Percent of Weekly Protein Supplied by Subsistence Activities
Claimant or Family Member Name
% of
Nola Maise
Cheryl Creppe l
70%
70%
Protein
DEEPWATER HORIZON
CLAIMS CENTER
ECONOMIC & PROPERTY DAMAGE Ct.AlHS
C.
CiJl..IM.ll.NT AND FAM!L'Y MEMBER INFORMATION
In the section below, you must state: (A) your name or the name of the family member who relied on your subsistence
activities; (B) age at the time that your losses began; (C) gender; (D) Social Security Number; and (E) percent of your or
your family member's total diet provided by your subsistence activities. The Claims Administrator will not pay consumption
losses in excess of 45% of a claimant or a family member's diet. The Claims Administrator determined that 45% is the
maximum reasonable percentage a claimant may claim to have come from subsistence activities. Example: If you could not
harvest Seafood or Game beginning on 4/20/10, you were 50 years old on that date and20%of the food you eat comes from
_y_our harvests _y_ou would com_Qlete the table as seen in the exam_Qle below.
A. Name
c. Gender
B.Age
:; Exi'
Jol)n Poe
50
[g] Male
1.
Kim Champlin
54
2.
Ray Herron
67
3.
Barry Herron
53
4.
Matt Herron
49
s.
Michael Herron
36
6.
Sheena Herron
25
7.
Horace Maise
80
8.
Nola Maise
77
Ill Male
Ill Male
Ill Male
Ill Male
Ill Male
D Male
Ill Male
D Male
9.
Cheryl Creppel
55
0Male
10.
Male
D.SodalSecurity
Number
E. Percent of Diet From

Subsistence Activities
(Maximum Allowable4SO/o)
123-45-6789
20to
D Female
D Female
D Female
D Female
D Female
D Female
Ill Female
D Female
Ill Female
Ill Female
D Female
D.
45%
45%
45%
45%
45%
45%
45%
45%
45%
'
SIGNATURE
I certify and declare under penalty of perjury pursuant to 28 U.S.C. Section 1746 that all the information I have provided in
this Interview Form (and in any pages I have attached to or submitted with this Interview Form to provide additional
information requested in this Interview Form) is true and accurate to the best of my knowledge, and that supporting
documents attached to or submitted with this Interview Form and the information contained therein are true, accurate, and
complete to the best of my knowledge, and I understand that false statements or claims made in connection with this
Interview Form may result in fines, imprisonment, and/or any other remedy available by law to the Federal Government, and
that suspicious claims will be forwarded to federal, state, and local law enforcement agencies for possible investigation and
prosecution.
An attorney may sign the claimant's name on this Interview Form if the claimant has authorized the attorney in a Power of
Attorney Agreement, a retainer agreement, or other document signed by the claimant in which the claimant has authorized
the attorney or law firm to pursue claims for the claimant arising out of the Deepwater Horizon Incident. If the attorney
chooses this option, the attorney must either submit, or have already submitted, a PDF of the signed authorization from the
claimant before the signature can be accepted. If the attorney does not have a signed authorization from the claimant, the
attorney may use the Power of Attorney Form created by the Claims Administrator for this purpose (POA-1), which is
available using the Forms section of the website, www.deepwaterhorizonsettlements.com.
As the authorized attorney, by signing below, you are certifying that you have the required written authorization from the
claimant to pursue claims for the claimant arising out of the Deepwater Horizon Incident on their behalf and have submitted
this authorization.
SUB-2
v.2
WWW, DEEPWATERHORIZONECONOMICSETTLEMENT .COM
Page 2 of 3
Claimant ID:
Claim ID:
DEEPWATER HORIZON
CLAIMS CENTER
ECONOMIC& PROPERTY OAM.\GE .a.MMS
Claimant
Signature
13
Signature
(Month/Day/Year)
Date
Signed:
Attorney
Signature
13
Signature
Soren Gisleson
(MonthfDay{Year)
Date
Signed:
SUB-2
v.2
WWW .DEEPWATERHORIZONECONOMICSETTLEMENT.COM
Page 3 of 3
Claimant ID:
Claim ID:
_before_
-__lh_e_Sp_._111_:_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
. .
I'.
--
Claimant's Position
I
Length of Claimant's Employment
(Month/oayiYeer)
D Hourly
$_
Claimant's Wage Rate Per Trtp
I provide my deckhand with a portion of my catch each

bip In payment for labor.
;:-.....1 LJally
D Weekly 0
Monthly
Inltlal11
Address
Identify your relatlonshlp to

the Claimant.
Non-Relative
DeScrlbe
Pound/Sacks:
Claimant provides the followlng each week for me:
In Exchange For:
(For Bartering Only) Clalmant provides the
following each week for me:
Pound/sacks:
In Exchange For:
. . . .1,_S_,._\_,_. . :. .-t_r_ _ _ _ __
r-o
E-
16 S
Il
'
the
__
before_
__
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I-. :
j
..
'
,Clalmant's Position
I
Clalmant's Wage Rate Per Trip
(Mcnt!l/Daytyear)
$_

b'lp In paymentfor labor.
Address
Identify your relatJonshlp to

the Claimant.
Hourly ::-..J ually
Weekly
Monthly
Inltlals=
Zip
Clly
Q1( Relative
Non-Relative
Desa1be Relatlonshlp: __lo

. . ;;__r_o_;._
Pound/Sacks:
Claimant provides the followlng each week for me:
-z 0
In Exchange For:
(For Bartering Only) Claimant provides the
Pound/Sacks:
In Exchange For:
r._--e_ r_ ___
I
I certify and declare under penalty of perjury pursuant to 28 U.S.C. 1746 that all the Information I have proV!ded In this
statement (and In any documents or other attachments submitted with this statement) Is true and correct
Date
Signed
utlit!L
(Month/Day/Year)
Name (Printed o Typed)
F.
area(s) you ftshed_J_h_u_

nted_
._ w_
_o_re_th_e_5p1_1_=-----------------
j
J
r
Claimant's Position
I
Claimant's Wage Rate Per Trip
(Month/DayiYeer)
D Hourly
$_

b1p In payment for labor.
::-..J wally
D Weekly 0
Monthly
Initials:
Address
Identify your relattonshlp to

the Claimant.
!if' Relative
Destt1be Relatlonshlp:-'CIA
.......
Pound/Sacks:
Clalmant provides the follbwlng each week for me:
In .Exchange For:
Pound/Sacks:
In Exchange For:
_ _ _ _ _ __
... ,_., _ .
. .
I certify and declare under penalty of perjury pursuant to 28 U.S.C. 1746 that all the Information I have provided In this
Statement (and In any documents or other attachments submitted with this Statement) Is true and correct.
.
Date
Signed
&t
fI I
(Month/Day/Year)
,,__
Third Party Signature
VV\ \ (. k4
f.
Name (Printed or "fyped)
rro\t\
area(s) you ftshed_J_h_u_n_l:ed

__befo_
_re_the
__Sp_m_:- - - - - - - - - - - - - - - - - -
(
J
-'
'.
Clalmant's Position
Length of Claimant's Employmeht

Claimant's Wage Rate Per Trtp
lMonuvOay1 rear)
$_

b1p In payment for labor.
Hourly ;.-' ually
(Month/OayiYeer)
D Weekly 0
Monthly
Inltla1s=
Address
Identify your relatlonshlp to

the Claimant.
Relatlve
Non-Relatlve
DeSa1be
Pound/Sacks:
Claimant provides the following each week for me:
In Exchange For:
Pound/Sacks:
In Exchange For:
__
I certify and declare under penalty of perjury pursuant to 28 U.S.C. _1746 that all the lnfomtatlon I have provided In this
.
Date
Gt
Signed
(Month/Day/Year)
t}, I l Q.
lhifdrtYSlgnature
\.\err-e>tt
Name (- nted or Typed)
Sp_11_1=---------------- -
area(s) you tlshed

_f_h_u_.nted_
.--_i>e_8to__re_the
__
1i.
;
,-
:....._:;:...__
Claimant's Position
Length of Clalmant's Employment

Clalmant's Wage Rate Per Trip
(Month/Day/Year)
(Moouv'Dllv1
D Hourly
$_

trtp In payment for labor.
;....J ually
D Weekly D Monthly
lnltlals'
Address
Identify your relattonshlp to
the Claimant.
Non-Relative
Describe Relationship:
Pound/Sacks:
Claimant provides the following each weak for me:

In Exchange For:
followlng each week for me:
Pound/Sacks:
In .:xchange For:
Relative
/J 11/V
I7
I certify and declare under penalty of perjury pursuant to 28 U.S.C. .1?46 tliatall thelnformatlon I have provided In this
Date
Signed
,1:7-
(Month/Day/Year)
R.I&
fle;M.o,J
a A/ ,tf
Name (Pr1nted or Typed)
:8
.: .
._ ..
.: .
1'cert:1Fy and declare under penalty of perjury pursuant to 28 U.S.C. 1746 that all the Information I have proVlded In this
statement (and In any documents or other attachments submitted with this Statement) Is true and rorrect.
Date
l , I?, I
(Month/Dav/Year)
"2-
tr/I //e,v /f_,//;////d

Name {Printed or Typed)

5c.
Did the claimant identify his or her fishing and/or hunting grounds?
Yes
5d.
Did the claimant describe the equipment he or she used to fish and/or hunt?
Yes
5e.
Did the claimant identify the percentage of Subsistence resources he or she relied
on pre-Spill that came from areas that were closed or impaired due to or resulting
from the Spill?
Yes
Did the claimant sign the Claim Form or Claimant Sworn Written Statement?
Yes
5f.
6.
Identify the species and amount(s) of Seafood and/or Game the claimant could not
obtain for Subsistence use?
Not Provided
Species
7.
Species
Weight
Percentage Distributed
as Food
Percent Bartered
Blue Crab
500.00
100.00
0.00
Flounder
50.00
100.00
0.00
Oysters
6500.00
100.00
0.00
Redfish (Red Drum)
50.00
100.00
0.00
Shrimp
800.00
100.00
0.00
Identify the information the claimant included in a Subsistence Claimant Sworn Written Statement for
Bartering Losses.
Not Provided
Not Provided
7a. Does the claimant barter exclusively under one or more Commercial Fishing Licenses?
7b. Identify the location(s) where the claimant bartered Seafood or Game.
C"ty
1
St t
a e
Dealers/Fresh Products License

Submitted?
Claimant Bartered with

License Dealer?
?f Did the claimant identify or submit: (1) rules that specifically authorize bartering activity; or (2)
rules that confirm that bartering activity is not prohibited in the claimed location(s)?
7g. Identify the rules the claimant submitted to verify his or her legal bartering activity.
7h. Did the claimant or claimant's attorney sign the Claimant Sworn Written Statement?
B.
Identify the information a third party barterer included in his or her Third Party Sworn Written
Statement:
Not Provided
Ba Did the third party identify the species and amount of each species he or she bartered with the
claimant?
Sb. Did the third party identify the frequency in which he or she bartered with the claimant?
Be Did the third party identify the types of items, services or goods the claimant received in
exchange for Seafood or Game?
Bd . Did the third party sign the Sworn Written Statement?
9.
Identify the Claimed Loss Period(s):
04/20/2010
10.
12/31/2011
Identify the claimant's fishing and/or hunting location Closure Period.
Not Provided
Unverified
Not Provided

Fishing Closure(s):
Location: Louisiana
Closure
.
,
Hunting or Fishing
Location
Closure Start Date
Closure End Date
Fishing
Louisiana
06/02/2010
01/12/2011
Fishing
Louisiana
05/20/2010
01/12/2011
Fishing
Louisiana
08/14/2010
01/12/2011
Fishing
Louisiana
01/12/2011
01/12/2011
Fishing
Louisiana
06/15/2010
01/12/2011
Fishing
Louisiana
05/09/2010
01/12/2011
Fishing
Louisiana
05/10/2010
01/12/2011
Fishing
Louisiana
07/29/2010
01/12/2011
Fishing
Louisiana
09/23/2010
01/12/2011
Fishing
Louisiana
07/07/2010
01/12/2011
Fishing
Louisiana
05/12/2010
01/12/2011
Fishing
Louisiana
07/05/2010
01/12/2011
Fishing
Louisiana
05/14/2010
01/12/2011
Fishing
Louisiana
05/15/2010
01/12/2011
Fishing
Louisiana
05/16/2010
01/12/2011
Fishing
Louisiana
07/02/2010
01/12/2011
Fishing
Louisiana
05/22/2010
01/12/2011
Fishing
Louisiana
07/01/2010
01/12/2011
Fishing
Louisiana
05/18/2010
01/12/2011
Fishing
Louisiana
06/09/2010
01/12/2011
Fishing
Louisiana
06/25/2010
01/12/2011
Fishing
Louisiana
06/23/2010
01/12/2011
Fishing
Louisiana
05/19/2010
01/12/2011
Fishing
Louisiana
05/26/2010
01/12/2011
Fishing
Louisiana
06/14/2010
01/12/2011
Fishing
Louisiana
05/21/2010
01/12/2011
Fishing
Louisiana
06/12/2010
01/12/2011
Fishing
Louisiana
06/07/2010
01/12/2011
Fishing
Louisiana
06/03/2010
01/12/2011
Fishing
Louisiana
06/08/2010
01/12/2011
Fishing
Louisiana
05/24/2010
01/12/2011
Fishing
Louisiana
05/28/2010
01/12/2011
Fishing
Louisiana
06/06/2010
01/12/2011
Fishing
Louisiana
05/27/2010
01/12/2011
Fishing
Louisiana
11/04/2010
01/12/2011
Fishing
Louisiana
05/18/2010
01/12/2011
Fishing
Louisiana
12/07/2010
04/29/2011
Fishing
Louisiana
10/25/2010
01/12/2011
Fishing
Louisiana
09/25/2010
01/12/2011

Fishing
Louisiana
08/21/2010
01/12/2011
Fishing
Louisiana
09/08/2010
01/12/2011
Fishing
Louisiana
07/21/2010
01/12/2011
Fishing
Louisiana
06/12/2010
01/12/2011
Fishing
Louisiana
06/06/2010
01/12/2011
Fishing
Louisiana
04/30/2010
01/12/2011
Fishing
Louisiana
05/28/2010
01/12/2011
Fishing
Louisiana
05/27/2010
01/12/2011
Fishing
Louisiana
06/07/2010
01/12/2011
Fishing
Louisiana
05/26/2010
01/12/2011
Fishing
Louisiana
06/08/2010
01/12/2011
Fishing
Louisiana
06/06/2010
01/12/2011
Fishing
Louisiana
05/24/2010
01/12/2011
Fishing
Louisiana
06/09/2010
01/12/2011
Fishing
Louisiana
05/22/2010
01/12/2011
Fishing
Louisiana
06/12/2010
01/12/2011
Fishing
Louisiana
06/14/2010
01/12/2011
Fishing
Louisiana
06/03/2010
01/12/2011
Fishing
Louisiana
06/15/2010
01/12/2011
Fishing
Louisiana
06/02/2010
01/12/2011
Fishing
Louisiana
05/21/2010
01/12/2011
Fishing
Louisiana
05/20/2010
01/12/2011
Fishing
Louisiana
06/23/2010
01/12/2011
Fishing
Louisiana
05/19/2010
01/12/2011
Fishing
Louisiana
06/25/2010
01/12/2011
Fishing
Louisiana
05/18/2010
01/12/2011
Fishing
Louisiana
07/01/2010
01/12/2011
Fishing
Louisiana
05/16/2010
01/12/2011
Fishing
Louisiana
07/02/2010
01/12/2011
Fishing
Louisiana
05/15/2010
01/12/2011
Fishing
Louisiana
07/05/2010
01/12/2011
Fishing
Louisiana
05/14/2010
01/12/2011
Fishing
Louisiana
07/07/2010
01/12/2011
Fishing
Louisiana
05/12/2010
01/12/2011
Fishing
Louisiana
07/14/2010
01/12/2011
Fishing
Louisiana
04/30/2010
01/12/2011
Fishing
Louisiana
07/29/2010
01/12/2011
Fishing
Louisiana
05/10/2010
01/12/2011
Fishing
Louisiana
05/09/2010
01/12/2011
Fishing
Louisiana
08/20/2010
01/12/2011
Fishing
Louisiana
08/14/2010
01/12/2011
Fishing
Louisiana
09/23/2010
01/12/2011

11c. Member Name:
Herron, Ray
11d. Age Reported on Interview Form:
67
11e. Date of Birth
Date of Death
11f. Social Security Number:

11g. Gender:
11 h. Percent of Diet from Subsistence Activities
45.00
11a. Relationship:
11b. Name:
Barry Herron
11c. Member Name:
Herron, Barry
53
Male
Claimant
Female
11e. Date of Birth
Not Provided
Family Member
Date of Death

11g. Gender:
45.00
11a. Relationship:
11 b. Name:
Matt Herron
11c. Member Name:
Herron, Matt
49
Male
Claimant
Female
11e. Date of Birth
Not Provided
Family Member
Date of Death

11 g. Gender:
45.00
11a. Relationship:
11b. Name:
Michael Herron
11c. Member Name:
Herron, Michael
36
Male
Claimant
Female
11e. Date of Birth
Not Provided
Family Member
Date of Death
11 f. Social Security Number:

11g. Gender:
11h. Percent of Diet from Subsistence Activities
45.00
11a. Relationship:
11b. Name:
Sheena Herron
11c. Member Name:
Herron, Sheena
25
Male
Claimant
Female
Not Provided
Family Member
Date of Death
11e. Date of Birth

11g. Gender:
45.00
Male
Female
Not Provided

11a. Relationship:
11b. Name:
Horace Maise
11c. Member Name:
Maise, Horace
80
Claimant
11e. Date of Birth
Family Member
Date of Death

11g. Gender:
45.00
11a. Relationship:
11b. Name:
Nola Maise
11c. Member Name:
Maise, Nola
77
Male
Claimant
Female
11e. Date of Birth
Not Provided
Family Member
Date of Death
11g. Gender:
11h. Percent of Diet from Subsistence Activities
45.00
11a. Relationship:
11b. Name:
Cheryl Crepppel
11c. Member Name:
Crepppel, Cheryl
55
Male
Claimant
Female
11e. Date of Birth
Not Provided
Family Member
Date of Death

11g. Gender:
45.00
Male
Female
Not Provided
Step 2: Summary
Distribution
Family Member
Member Name
Age
Gender
Reasonable
Daily
Percent of
Allowable
Calorie
Diet from
Subsistence Consumption Subsistence
Calories
Status of
SSN
Barry Herron
Herron, Barry
53
Male
45.00
3200.00
1440.00
Unverified Tax ID Not

Provided
Cheryl Crepppel
Crepppel, Cheryl
55
Female
45.00
2400.00
1080.00

Provided

Provided
Horace Maise
Maise, Horace
80
Male
45.00
2600.00
1170.00
Kim Champlin
Champlin, Kim
50
Male
45.00
3700.00
1665.00
Verified
Matt Herron
Herron, Matt
49
Male
45.00
3300.00
1485.00

Provided
Michael Herron
Herron, Michael
36
Male
45.00
3300.00
1485.00

Provided
Nola Maise
Maise, Nola
77
Female
45.00
2200.00
990.00

Provided
Ray Herron
Herron, Ray
67
Male
45.00
3000.00
1350.00

Provided
Sheena Herron
Herron, Sheena
25
Female
45.00
2600.00
1170.00

Provided
26300.00
11835.00
Totals
Harvest
Species
Gross Harvest
Loss (lbs.)
Consumable
Portion of
Harvest
Consumable
Retail
Product
Avg Price 2010
Avg Price
2011
Loss Days
Blue Crab
500.00
17
85.00
$7.64
$8.57
Flounder
50.00
39
19.50
$4.17
Oysters
6,500.00
11
715.00
Redfish (Red
Drum)
50.00
41
Shrimp
800.00
46
Loss
2010
% Loss 2011
444
18.00%
82.00%
$4.19
444
18.00%
82.00%
$6.27
$5.99
444
18.00%
82 .00%
20.50
$6.55
$6.46
444
18.00%
82.00%
368.00
$6.26
$6.75
444
18.00%
82.00%
0/o
Totals
Consumed/Bartered Calculations
Bartered
Consumed
Total
Species
Total Retail
Value 2010
Total Retail
Value 2011
D/o
Consumed
Kcal/lbs.
Total Caloric
Value
Consumed
Total
Retail
Value
2010
Total
Retail
Value 2011
Blue Crab
$116.89
$597.33
100.00%
395.00
33,575.00
$0.00
$0.00
0.00%
$714.22
Shrimp
$414.66
$2,036.88
100.00%
322.00
118,496.00
$0.00
$0.00
0.00%
$2,451.54
Oysters
$806.95
$3,511.94
100.00%
231.00
165,165.00
$0.00
$0.00
0.00%
$4,318.89
Flounder
$14.64
$67.00
100.00%
318.00
6,201.00
$0.00
$0.00
0.00%
$81.63
Redfish (Red
Drum)
$24.17
$108.59
100.00%
544.00
11,152.00
$0.00
$0.00
0.00%
$132.76
Totals
334,589.00
O/o
Bartered
Total Post
Spill Retail
Value

Calculation
Retail Value - Consumed
$7,699.04
Retail Value - Bartered
$0.00
Loss Period in Days
444
Total caloric Value Consumed
334,589.00
Daily caloric Value Consumed
753.58
Daily Allowable Subsistence calories
11,835.00
Consumption to Distribution Ratio
0.06
Value of Lost Harvest - Consumed if [CR]<l
7,699.04
Total Compensation Amount Pre RTP
7,699.04
RTP(2.25)
17,322.84
Total Compensation Amount
25,021.88
Incompleteness Reason
Reason Number
Description
Denial Reason
Reason Number
Description
Result
Claim Result
Compensation Amount
Payable
$25,021.88

Redacted Champlin Claims

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Redacted Champlin Claims

Uploaded by

Copyright:

Available Formats

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 4 of 56

1. Is your Subsistence Claim based on hunting

3. Are you a Commercial Fisherman or Seafood

TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORIZONSETTLEMENTS.COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 5 of 56

TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWAIERHORIZONSETILEMENTS.COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 6 of 56

TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORJZONSETTLEMENTS.COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 7 of 56

8. Do you fish or hunt to ha1Vest, catch, barter,

If you checked "Yes" for Question 8, explain.

TO FILE YOUR CLAIM ONLINE VISIT WWW. DEEPWATERHORIZONSITTLEMENTS.COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 8 of 56

11. Did you continue to fish and/or hunt for subsistence

12. Did you stop fishing and/or hunting for subsistence

Dates Closed or Impaired/Harmed

From _1_J_]J)_j 2010 to -1L)_J__J 2012

TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORIZONSETTLEMENTS.COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 9 of 56

obligation to notify the Claims Administrator if your address changes.

/S/ Soren Gisleson

TO FILE YOUR CLAIM ONLINE VISIT WWW.DEEPWATERHORIZONSITTLEMENTS.COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 11 of 56

Name: Nola Maise

Relationship: father in law

Name: Sheena Herron

PERCENT OF WEEKLY PROTEIN SUPPUEO BY SUBSISTENCE Acn:vrrIES

Claimant or Family Member Name

Kim Champlain - 70%

Ray Herron - 70%

Barry Herron - 70%

Matt Herron - 70%

Michael Herron - 70%

Sheena Herron - 70%

Horse Maise - 70%

NAME OF T:HE PERSON WHO COMpLETED THIS FORM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 12 of 56

crab, shrimp, oyster, flounder, redflsh

Part 8. contd. Age and Gender Information

Claimant or Family Member Name and

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 14 of 56

CiJl..IM.ll.NT AND FAM!L'Y MEMBER INFORMATION

E. Percent of Diet From

WWW, DEEPWATERHORIZONECONOMICSETTLEMENT .COM

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 15 of 56

Name (Printed or Typed)

Name (Printed or Typed)

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 16 of 56

Claimant's Wage Rate Per Trtp

I provide my deckhand with a portion of my catch each

Identify your relatlonshlp to

Claimant provides the followlng each week for me:

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 18 of 56

I provide my deckhand with a portion of my catch each

Identify your relatJonshlp to

Hourly ::-..J ually

Desa1be Relatlonshlp: __lo

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 19 of 56

Name (Printed o Typed)

Case 2:10-md-02179-CJB-SS Document 13575-8 Filed 10/29/14 Page 20 of 56

area(s) you ftshed_J_h_u_

I provide my deckhand with a portion of my catch each

Identify your relattonshlp to