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� <br />CLAIM FORtI�i <br />KOPPERS COMPANY, INC. kln/a BEAZER EAST, INC. <br />PHENOLIC FOAM ROOF INSULATION (PFRI) CLASS ACTION SETTLEMENT <br />KoppersExeltberm ;YEra, Koppere Rx, Genstar, Pik#sburgh Corntng andLoadmasterr'' �r�er PERP') <br />� Check �ere if you are not the cwrentproperry owner. f you are not the current <br />groperty owner, attac,b a��.s�ign.ui�a[ of tha i'FRI claim �om tY�e current <br />Owner of 1he property to you. _ <br />� �����t� <br />�• Name of the Property Owner(s): —�� � � �� �' � <br />(Including Co-Owner(s): <br />(See paragraph A cf the atrached instnictions) . <br />Name and Address of Owner's Authorized Contact Person� r� �� " ��� `f ���' �� ��� � <br />Property Address: 1200 Woodhill �rivc <br />Street — <br />Rnseviile, 111.�' S5113 <br />State � ��� <br />Mailing Address (if different): ;�(4 6� ��� �d--� <br />���U� ���f� ��� <br />City State Zip <br />Ttiephane�• �, � ������' � � � � <br />Gr{ Evening Fax <br />F-'�[�11; <br />Name of Building: Rosevil(e lcc Arena <br />H�. Proof of Property Ownership; � Yau rtt:t�t include attachmenu derrribed in paragraph <br />B af the atrached ins�rucfions. <br />Have ��a made ■ Prior CLvm with Koppers Company, � YES <br />Inc. or Beazer,East, Ine, ❑ <br />NO <br />If yes, please provide the file or claim # assigned to <br />Your claim. Upon receipt by the Claims Offiee of this � <br />Claim �orm with yonr prior claim #, the Clsitns Office <br />Will notify you in writing of any additional information <br />Which it �aw need to process your claim. <br />You may skip to Item F, below <br />If "No", proceed to Item C, below <br />C. Proof that roof contains Beazer PFR� over a metal � '��y ��t ��* � d< <� ���*'��i <br />roof deck: described in paragraph C of the attached <br />* * See Exhibit * * instructions <br />