OPT-IN FORM

THREE CLASS ACTION CASES

TITLE 10

BASSEN

U.S. ACTIVE DUTY OR RESERVE

TITLE 32

KONIE

U.S. NATIONAL GUARD

TITLE 10

HARKINS

U.S. COAST GUARD ACTIVE DUTY OR RESERVE

Opt-in Qualification Form

Complete the Opt-In Form to see if you qualify.

1Contact Information

2Service History

3Your Experience

4Opt-In Confirmation

All clients and potential clients are required to complete this opt-in form.

Contact Information

Full Name*

First Name Last Name

Phone Number*

Email Address*

Please select your branch of service in 2021*

Address*

Your Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you currently on full-time active duty or on active service in the reserves?*

YES

Consent*

By checking this box, I expressly agree to our Terms of Service and Privacy Policy. You authorize us, our service providers and partners to contact you by email and phone using the details you provided, as well as other automated communication technologies, which could include SMS text messages even if your phone number is listed on any state, federal or other Do Not Call lists. I understand I may opt out at any time from communications to avoid receiving calls or SMS messages. You acknowledge that there is no guarantee that we will be able to represent you until we have reviewed all the materials related to your case. *

Service History

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Please select where you currently serve:*

Army Active Duty (Regular Army)

Army ADOS (Active Duty Operational Support)

Army AGR (Active Guard Reserve)

Army Reserve (USAR)

Army Technician Status (Dual Status Technician)

Please select where you currently serve:*

Marine Corps Active Duty (Regular Marine Corps)

Marine Corps Reserve (USMCR)

Please select where you currently serve:*

Navy Active Duty (Regular Navy)

Navy FTS (Full-Time Support)

Navy Reserve (USNR)

Please select where you currently serve:*

Air Force Active Duty (Regular Air Force)

Air Force ADOS (Active Duty Operational Support)

Air Force AGR (Active Guard Reserve)

Air Force Reserve (USAFR)

Air Force Technician Status (Dual Status Technician)

Please select where you currently serve:*

Space Force Active Duty (Regular Space Force)

Space Force Reserve (planned)

Please select where you currently serve:*

Active Duty Coast Guard

Coast Guard Reserves

Please select where you currently serve:*

Army National Guard – Title 32

Army National Guard - Title 10

Air National Guard – Title 32

Air National Guard – Title 10

AGR (Active Guard Reserve)

M-Day (Traditional part-time service)

State Active Duty (SAD)

Dual Status Technician

ADOS / ADSW (short-term active duty orders)

What is you current rank?*

(E - Enlisted, W - Warrant Officer, O - Commissioned Officer)

What is your current pay grade?*

Please tell us about your time serving in the :

When did you initially join the ?*

Day

Month

Year

If you rejoined the , when did your current (active) contract start?

Day

Month

Year

When does your current (active) contract end?*

Day

Month

Year

How many years and months did you sign for under your current contract?

Years

Months

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Please select where you last served:*

Army Active Duty (Regular Army)

Army ADOS (Active Duty Operational Support)

Army AGR (Active Guard Reserve)

Army Reserve (USAR)

Army Technician Status (Dual Status Technician)

Please select where you last served:*

Marine Corps Active Duty (Regular Marine Corps)

Marine Corps Reserve (USMCR)

Please select where you last served:*

Navy Active Duty (Regular Navy)

Navy FTS (Full-Time Support)

Navy Reserve (USNR)

Please select where you last served:*

Air Force Active Duty (Regular Air Force)

Air Force ADOS (Active Duty Operational Support)

Air Force AGR (Active Guard Reserve)

Air Force Reserve (USAFR)

Air Force Technician Status (Dual Status Technician)

Please select where you last served:*

Space Force Active Duty (Regular Space Force)

Space Force Reserve (planned)

Please select where you last served:*

Active Duty Coast Guard

Coast Guard Reserves

Please select where you last served:*

Army National Guard – Title 32

Army National Guard – Title 10

Air National Guard – Title 32

Air National Guard – Title 10

AGR (Active Guard Reserve)

M-Day (Traditional part-time service)

State Active Duty (SAD)

Dual Status Technician

ADOS / ADSW (short-term active duty orders)

What was the last rank you achieved?*

(E - Enlisted, W - Warrant Officer, O - Commissioned Officer)

What was your last pay grade?*

Please tell us about your time serving in the :

Started Service  (Service Entry Date)*

Day

Month

Year

End of Service (End of Service Date)*

Day

Month

Year

oops..please check all dates on this page are correct.

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Did you file a Religious Accommodation Request (RAR)?

YES

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When did you file this Religious Accommodation Request (RAR)?

Month*

Year*

Was the Religious Accommodation Request (RAR) denied?*

YES

UNSURE / NO ANSWER

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What date was the Religious Accommodation Request (RAR) denied?

Month*

Year*

Did you appeal the Religious Accommodation Request (RAR) denial?*

YES

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When did you appeal the RAR denial?

Month*

Year*

Was the Religious Accommodation Request (RAR) appeal denied?*

YES

NO RULING

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What was the date of the appeal decision?

Month*

Year*

YOUR EXPERIENCE BEING UNVACCINATED IN THE

Please select any of the following that apply to your experience being unvaccinated in the : (select all that apply)*

Involuntarily separated

Left service at my ETS as part of an administrative exemption

Separated rather than face court-martial or an adverse involuntary administrative separation

Removed from a promotion list

Removed from consideration by a promotion or any other board

Removed from a professional school

Prohibited from a promotion or attendance at a professional school

Removed from Command

Removed from a position and lost entitlement to pay as a result

Remained on Active Duty despite the actions taken against me

Affected my retirement in some way

Other

If other, please explain your experience here:*

Do you know your address at time of discharge?*

YES

Address at time of discharge*

Street Address City State ZIP Code

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Were you ever issued a DD-214?*

I was issued a DD-214

I was never issued a DD-214

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Please give the Month and Year when you were first issued a DD-214:

Month*

Year*

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Were you ever discharged as a result of being unvaccinated in the ?*

YES

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What type of discharge did you receive?*

Your Re-enlistment Code

Your Separation Code

How many (years/months) were left on your obligation to the at the time of your discharge?

Years*

Months*

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As a direct result of being unvaccinated in the , please select EACH OF the situations that apply:

Had money recouped by the

Lost my education benefits

Was indebted to the government as a result

None of the above

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How much money was recouped by the as a result of your discharge?

If you were discharged, were you eligible for federal benefits from the Veterans affairs (VA)?

Yes - Activated Under Title 10, Deployed, or Activated for Domestic Operations Under Title 32

Not Applicable

Were you ever federally activated under Title 10 or AGR Orders, or deployed overseas while in the National Guard?

Yes - Activated Under Title 10, Deployed, or Activated for Domestic Operations Under Title 32

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At the time of refusing the vaccine (approx. 2021) were you receiving any monthly special or incentive pay?*

YES

Select any of the monthly special or incentive pays you were receiving at the time of refusing the vaccine?*

Assignment Incentive Pay (AIP)

Career Sea Pay (CSP)

Diving Duty Pay

Foreign Language Proficiency Bonus (FLPB)

Hostile Fire Pay (HFP) / Imminent Danger Pay (IDP)

Medical Officer Special Pays

Nurse Corps Officer Special Pays

Special Duty Assignment Pay (SDAP)

Aviation Incentive Pay (AvIP)

Cyber Skills Incentive Pay

Family Separation Allowance (FSA)

Hardship Duty Pay (HDP)

Jump Pay / Parachute Duty Pay

Montgomery GI Bill Kicker

Optometrist and Veterinarian Pays

Submarine Duty Pay (SUBPAY)

Career Enlisted Flyer Incentive Pay (CEFIP)

Dental Officer Special Pays

Flight Pay (AvIP for Enlisted)

Hazardous Duty Incentive Pay (HDIP)

Korea Assignment Incentive Program (KAIP)

Nuclear Officer Incentive Pay

Pharmacy Officer Pay

Other

Select all that may apply.

What was the total additional monthly payment amount you received in special or incentive pay?*

Did you receive BAH (Basic Allowance for Housing) with dependents or without dependents?*

YES WITH DEPENDENTS

YES WITHOUT DEPENDENTS

Have you filed a DD-149 with the Board of Corrections of Military or Naval Records for any correction related to the COVID-19 Vaccine Mandate?*

YES

When did you file a DD-149 with the Board of Corrections of Military or Naval Records?*

Month

Day

Year

(Provide best estimated date if exact date is unknown)

Please provide your Board of Corrections of Military or Naval Records Case ID # here:

Did the Board of Corrections give a decision for your case?*

YES

When did you receive the decision from the Board of Corrections?*

Month

Day

Year

(Provide best estimated date if exact date is unknown)

What was the decision from the Board of Corrections?

Do you have any additional information you would like to provide regarding your submission to the Board of Corrections?

Were you eligible to re-enlist at the time of discharge?*

YES

UNSURE

Were you offered a Re-enlistment Board?*

YES

UNSURE

Were you ever contacted by the Return to Service team after leaving the ?*

YES

UNSURE

Did you return to service?

YES

UNSURE

What date did you return to service?

Month*

Year*

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Were you evaluated medically before you left the ?*

YES

After discharge, did you receive a disability rating from the Veterans Affairs (VA) Office?*

YES

IF YES, what was the rating*

ADDITIONAL INFORMATION FOR YOUR CLAIM

If you have additional information related to your back pay claim, not covered previously in this opt in form, please provide any details in the box provided below (not required):

YOU MUST CLICK SUBMIT OPT-IN FORM TO COMPLETE OPT-IN PROCESS

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OPT-IN FORM

THREE CLASS ACTION CASES

TITLE 10

BASSEN

TITLE 32

KONIE

TITLE 10

HARKINS

Opt-in Qualification Form

Contact Information

Service History

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YOUR EXPERIENCE BEING UNVACCINATED IN THE <strong class="mb-dynamic-value-282"></strong>

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ADDITIONAL INFORMATION FOR YOUR CLAIM

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