NT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Toyota, Lexus, and Scion Vehicles INSTRUCTIONS FOR REGISTERING/SUBMITTING A CLAIM FOR A SETTLEMENT PAYMENT Please Read These Instructions Carefully 1. Subject to certain limited exclusions, you are a person or entity eligible to register/submit a claim for a Settlement Payment if: ‘a, You owned or leased, on June 9, 2017, a Subject Vehicle distributed for sale or lease in the United States or its territories or possessions, AND you bring or have brought your Subject Vehicle to a Toyota, Lexus, or Scion dealership for the Takata Airbag Recall Remedy; of, b. You sold, or returned pursuant to a lease, a Subject Vehicle distributed for sale or lease in the United States or its territories or possessions after April 11, 2013 and before June 9, 2017, ifthe Subject Vehicle ‘was recalled prior to June 9, 2017. 2. To registerisubmit a claim for a Settlement Payment, you must either: . Submit an clectronic Registration/Claim Form online by visiting www.AutoAirbagSettlement.com (online registration will result in expedited processing); or, b. Submit a paper Registration/Claim Form by completing this form and returning it along with any required documentation by U.S. Mail or email to: Mailing Address Auto Airbag Settlement Settlement Notice Administrator PO. Box 3207 Portland, OR 97208-3207 Email: info@AutoAirbagSettlement.com 3. The deadline for submitting a Registration/Claim Form is as follows: a. Ifyou sold or returned, pursuant to a lease, a recalled Subject Vehicle after April 11, 2013 and before June 9, 2017, and your vehicle was recalled under the Takata Airbag Inflator Recall prior to June 9, 2017, you have one year from the date that the Settlement becomes final (the “Effective Date") to submit a Registration/Claim Form. », Ifyou owned or leased a Subject Vehicle on June 9, 2017, the deadline for submitting a Registration/Claim Form is one year after the Eifective Date, or one year after the date the Recall Remedy is performed on your Subject Vehicle, whichever is later, until the Final Registration/Claim Deadline is tea IMPORTANT: NO REGISTRATION/CLAIM FORMS MAY BE SUBMITTED AFTER THE FINAL REGISTRATIONCLAIM DEADLINE. THE EFFECTIVE DATE AND THE FINAL REGISTRATION/CLAIM DEADLINE ARE NOT YET KNOWN, BUT WILL BE POSTED PROMINENTLY ON THE SETTLEMENT WEBSITE, WWW.AUTOAIRBAGSETTLEMENT.COM, WHEN THEY ARE KNOWN. 4, Ifyou are or were the registered owner or lessee of more than one Subject Vehicle, you must submit a separate Registration/Claim Form for each Subject Vehicle to obtain a separate out-of-pocket Settlement Payment for each Subject Vehicle you own(ed) or lease(@). However, claims for unreimbursed expenses cannot be duplicative. SESAME on Page 2 of 7SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Toyota, Lexus, and Scion Vehicles 5. Capitalized terms in this Form have the same meaning as provided in the Settlement Agreement, which is available for download at www.AutoAirbagSettlement.com. The Long Form Notice, which is also available for download at www.AutoA irbagSettlement.com or by calling 1-888-735-5596, also explains key terms of the Settlement, including the definition of Effective Date. 6. Type or print legibly in blue or black ink. Do not use any highlighters. Provide all requested information ‘0 complete and submit this Form, attach supporting documentation, as specified below, and sign the Form, IMPORTANT: KEEP A COPY OF YOUR COMPLETED REGISTRATION/CLAIM FORM AND. THE SUPPORTING DOCUMENTS. ANY DOCUMENTS YOU SUBMIT WITH YOUR FORM WILL NOT BE RETURNED. IF YOUR CLAIM IS REJECTED FOR ANY REASON, YOU WI BE NOTIFIED AND GIVEN AN OPPORTUNITY TO ADDRESS ANY DEFICIENCIES. THE SETTLEMENT SPECIAL ADMINISTRATOR'S DECISIONS REGARDING CLAIMS FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES SUBMI FINAL AND CANNOT BE APPEALED. "ED BY CLASS MEMBERS IS SECTION I: CLASS MEMBER INFORMATION Please fill in the below contact information. This information will only be used to contact you regarding the Auto Airbag Settlement. Business Organization/Trust Name(9) (ifapplicable): Fit Name Mi: Last Name E lol eae) MIAIEIAIE TOT (a Sala? Address Jolelo Adres Colas Gi BATA] Cou ualriro] Phone: Isi)-Gla7)- Bea Email: Viz So ce [J & ZIP: DS] BS} Is th im WEA on Page 3 of 7SETTLEMENT REGISTRATION/CLAIM FORM. tuto Airbag Settlement for Certain Toyota, Lexus, and Scion Vehicles Please enter the Vekicle Identification Number (VIN) of your Subject Vehicle. The VIN can be found on the dashboard of the vehicle, the vehicle's registration, or the vehicle's title, and is 17 characters long. To confirm whether or not your vehicle is eligible for participation in the Auto Airbag Settlement, please visit www. AutodirbagSeitlement.com. E. Mayvera Rosarrd Vehicle Mdentification Number (VIN): € 27 [1 [Ble[al2le[slele ho] 4| TOYOTA SETTLEMENT SUBJECT VEHICLES Check the box next to your vehicle model and model year. Check only one. Toyota Corolla Toyota Matrix (2003 [2004 =[]200s [M2006 | (J2003 [2004 [2005 []2006 [2007 [)2008 =] 2009 = [}2010 | [)2007 [)2008 [)2009 [J 2010 Ou C22 C203 C24 | O20 Oo C203 Os C6 (C07 Toyota RAVS Toyota Sequoia (2004 = (2005 (2002 (2003 [2008 =) 2005 (2006 (2007 Toyota Sienna ‘Toyota Tundra C20 20122013 2m =| C2003 2004 ~=L 2005 +) 2006 ‘Toyota Yaris Toyota 4Runner (2006 =()2007 L)2008 =] 2009 | C2000 §=C201 C22 Caos O20 Cj2u [J202 O24 Ors [2016 [j207 ‘Toyota iM Lexus ES350 C2017 (2007 (2008 ~=C]2009 © Camo On D212 Lexus GX460 Lexus IS O20 C20 (22 [2013 | 2)2006 [2007 [)2008 ) 2009 O24 Cas C2016 O27 | O20 O20 O22 Oras Lexus IS-F Lexus 1S250/350 (2008 =L)2009 §=200 =) 201 D204 =[L2015 O22 =O203 = C2014 Lexus 182500/350C Lexus 1S350/300/200T Oe O21 (C22 O23 | O26 O27 O24 C2015 L WEA Page 4 of 7SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Toyota, Lexus, and Scion Vehicl Lexus RC-F Lexus LE-A Os (C2016 [207 D202 Lexus 350/300/200T Lexus SC430 Os (C26 C207 (2002 (2003 [2004 =) 2005 (2006 =[)2007 [}2008 —[] 2009 2010 ‘Scion iM ‘Scion XB 2016 (2008 ~=)2009 =Lj200 Liz O22 C203 (J204 ()2015 Kl Yes 1. Did you purchase or lease your Subject Vehicle before June 9, 2017? CINo i LX Yes 2. Did you still own or lease your Subject Vehicle on June 9, 2017? ous 3. Did you br I ee ee ee Recal No 4, Ifyou answered “No” to Question 2 in this Section, did you sell, or return pursuant to a lease, your |] Yes Subject Vehicle after April 11, 2013 and before June 9, 2017? No Edgardo Maver SECTION II: OU POCKET E Did you pay for any expenses, as further defined below, related to the Takata Airbag Inflator Recall | L_] Yes for your Subject Vehicle that have not been reimbursed by Toyota? [QNo Ifyou answered “Yes" to Question 1 in this Section, please complete the remainder of this Section and Section IV to submit a claim for reimbursement of the out-of-pocket expenses you incurred, in addition to a potential later payment of up to $250 from the Settlement Fund, Ifyou answered “No” to Question 1 inthis Section, please skip to and complete Section TV below to register for toil potential payments of upto $500 from the Setiement Fund, T | Ecce Page 5 of 7SETTLEMENT REGISTRATION/CLAIM FORM duto Airbag Settlement for Certain Toyota, Lexus, and Scion Vehicles The Settlement Special Administrator will process and approve payments from the Settlement Fund in ‘accordance with the terms of the Settlement Agreement. Payments for reimbursable out-of-pocket expenses will be made first, and if sufficient funds remain in the Settlemeni Fund at the end of each program year, that money will be paid to Class Members who: (a) submitted claims for out-of-pocket expenses in thai year or prior program years that were previously rejected: or (b) sought to register for a Residual Distribution payment only. Reimbursements for out-of-pocket expenses will be made on a first-in-first-out basis during years one through three, until the Settlement Fund is depleted for that year. If there are no more funds to reimburse Class Members in years one through three, those Class Members will be moved to subsequent years for reimbursement. If approved reimbursements to Class Members in year four and until the Final Reghsration/Claim Deadline exceed the amount availabe in the Settlement Fund, reimbursements will be made on a pro rata basis. Settlement Payments (excluding reimbursements for out-of-pocket expenses) are capped at $250 per Class Member in the program year in which the Class Member registers for a payment from the Residual Distribution (or a subsequent year if the Class Member is moved 1o the subsequent year due to insufficient funds in years one through three). Approved payments to Class Members to reimburse them for reasonable ‘out-of pocket expenses are not capped, unless pro rata reimbursements are required in year four. After the Final Registration/Claim Deadline, if sufficient funds remain in the Settlement Fund and it is administratively feasible, the remaining funds will be paid to all Class Members who registered/submitted 4a claim for a Seitlement Payment on a per capita basis, up to a maximum of $250 per Class Member. If there are additional funds remaining after paying all registered Class Members a maximum of 8250 per Class Member, and if it is administratively feasible, the remaining funds will be distributed per capita to all Class Members. Please periodically check the Settlement website, www.AutodirbagSettlement.com, for updates regarding the Settlement, including information about the deadlines for filing Registration/Claim Forms. 2, Please identify the reasonable out-of-pocket expenses you incurred relating to the Takata Airbag Inflator ee ee ‘The categories below are potentially eligible for reimbursement, but you may include other reasonable expenses you incurred related to the Takata ‘Airbag Inflator Recall for your Subject Vehicle, Please fil in as many expenses as apply. Rental car and transportation expenses after requesting and while awaiting the Recall Remedy from a Toyota, Lexus, or Scion Dealer: $ Towing charges to a Toyota, Lexus, or Scion Dealer for completion of the Recall Remedy: Childcare expenses necessary during the performance of the Recall Remedy by a Toyota, Lexus, or Scion Dealer: s | Costs associated (PSAN) inflators: ring driver or passenger front airbags containing Takata phase-stabilized ammonium-nitrate WGA Page 6 of 7T SETTLEMENT REGISTRATION/CLAIM FORM Auto Airbag Settlement for Certain Toyota, Lexus, and Scion Vehicles Lost wages resulting from lost time from work to drop off to, and pick up from, the Toyota, Lexus, or Scion Dealer for performance of Recall Remedy: s = Storage fees incurred after requesting and while awaiting Recall Remedy: $icisie eel If “Other,” please deseribe here: Noy YET IMPORTANT: IF YOU NEED MORE SPACE, PLEASE SUBMIT A SEPARATE PAGE WITH ADDITIONAL INFORMATION. 3, If you have any invoices, receipts, or other documents that support the expenses identified in response to Question 2 above, including a written explanation of the necessity ofthe expenses you lease submit them. Ifyou have such documents supporting your expense, you may be required to submit them. At the discretion of the Settlement Special Administrator, reimbursement for certain reasonable out-of-pocket ‘expenses may be made to Class Members even in the absence of any supporting documentation, and the ‘Settlement Special Administrator may approve and pay for other reimbursable claims that the Settlement Special Administrator deems to be reasonable out-of-pocket expenses. 1 VONs| 1 affirm, under penalty of perjury and under the laws of the United States of America, that the information in this Registration/Claim Form is true and correct to the best of my knowledge, information, and belief, and that Iam the sole and exclusive owner of all claims being released by the Settlement. I understand that my Registration/Claim Form may be subject to audit, verification, and review by the Settlement Special Administrator and Court, I also understand that ff my Regstration/Ciaim Form is found tobe fraudulent, I wil not receive any payment from the ttlement Fur Signature: Date: ol|- VAY Mowe MM DD ‘Toyota, Lexus, or Scion, the Settlement Special Administrator, and/or the Settlement Notice Administrator are not responsible for any documents that are misdelivered, lost, illegible, damaged, destroyed, or otherwise not received by U.S. Mail, email, or other delivery method. SEPARA aon Page 7 of 7