Claims

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Name of Claimant(Required)

Address for Notices

Your Email Address(Required)

Were you or any member of your immediate family an employee or contractor of Reliable One Resources, Quantum Filtration, or any of their affiliates
Entity You Assert a Claim Against (check all that apply):

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    I, the undersigned, hereby declares that all the information provided in this Proof of Claim, including all attachments to the Proof of Claim, are true and correct and that I am authorized to make this Claim. By submitting this Proof of Claim to the Receiver, I consent to notices being provided to me at the address stated in the Proof of Claim. I acknowledge and agree that submitting this Proof of Claim by electronic means (e-mail or submission through the Receiver’s website) shall constitute a valid signature [seem redundant to me, and it might be necessary to be redundant.