Contribution Agreement Form

IMPORTANT: TO BE A PART OF THE MASS ARBITRATION, PLEASE FOLLOW THE INSTRUCTIONS ON THIS PAGE AND BOTH PDF FORMS.

PLEASE READ THE FORMS CAREFULLY AND THOROUGHLY.

NOTE: ANYONE CAN SUBMIT A FORM. IT DOES NOT MATTER WHERE YOU ARE FROM, YOU DO NOT HAVE TO BE FROM THE UNITED STATES.

PLEASE DOWNLOAD BOTH PDFs AND READ THROUGH THE INSTRUCTIONS. SUBMIT THE SIGNED CONTRIBUTION AGREEMENT BELOW, AS WELL AS A COPY OF YOUR OPENBLOCK WALLET ADDRESS.

Name *

First

Last

Email *

File Upload *

Click or drag files to this area to upload. You can upload up to 5 files.

Note: Only upload a signed version of the CONTRIBUTION AGREEMENT PDF. The signature pages are on pages 15 and 16. Only sign once you have read and understood agreement and you want to join the mass arbitration lawsuit.

Upload Copy of Gnosis Chain/xDAI Wallet Address: *

Checkboxes *

• I agree that I have read the Contribution Agreement and I understand that I must also follow the directions in setting up OpenBlock Wallet to be apart of this matter.

Briefly explain how PayPal froze or took your funds:

Additional questions: (optional)

If you have any additional questions about this matter, please submit here.

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