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If your business accepted Visa or MasterCard payments anytime from January 1, 2004 to January 25, 2019, you may have a pending Settlement. Once you fill out this form, you will receive an email with CCS Retainer Agreement to sign, at the time you engage CCS we will assure you that your Claim will be processed on time with the Claims Administrator.

Please submit an individual form per each Tax Payer.

Referral Partner

Claimant Type

Entity Legal Name

DBA Name

Business Type

State where Business is Registered

First Name (Authorized Business Representative)

Last Name (Authorized Business Representative)

Title

EIN

Physical Address

Address Line 2

City

State

State Code

Zip code

Country

How long have you been in business?

Phone (xxx)xxx-xxxx

What type of business is this? (Restaurant, Hotel, Salon, etc.)

Are you still in business?

NoYes

YTD Gross Revenue reported in Debit & Credit Card transactions for the last 12 months.

How many locations do you have ?

Important Notes

Please provide the contact information for the person in your business that will be providing us with any documentation or information for your claim. Full Name:

Phone

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