Exhibit A-3 

PROOF OF CLAIM AND RELEASE FORM 

A. GENERAL INSTRUCTIONS & INFORMATION 

1. You are urged to read carefully the accompanying Notice of Pendency and Settlement of Class 

Action (the “Notice”). All capitalized terms used herein not otherwise defined herein shall have the same 

meaning as defined in the Notice. 

2. To file a claim and recover under the Settlement of this Action, you must submit this Proof of 

Claim and Release form (the “Proof of Claim”). However, such filing is not a guarantee that you will 

share in the proceeds of the Settlement in the Action. 

3. You must mail your completed and signed Proof of Claim postmarked on or before ______, 

2021, addressed to the Claims Administrator at: 

4. If you are a Class Member and you do not timely request exclusion, you will be bound by the 

terms of any Judgment entered in the Action. 

5. If you are not a Class Member, do not submit a Proof of Claim. 

6. If you need assistance filling out this Proof of Claim, please contact the Claims 

Administrator. 

B. INSTRUCTIONS FOR FILLING OUT THE PROOF OF CLAIM 

Important additional information regarding the Settlement and this Proof of Claim is 

contained in the accompanying Notice. Please refer to the proposed Plan of Allocation set 

forth in the accompanying Notice for a detailed explanation of how a Claimant’s Recognized 

Loss will be calculated. 

1. In order to be eligible to participate in the distribution of the Net Settlement Fund, a claimant 

(“Claimant”) must have purchased RTI Surgical Holdings, Inc. (“RTI”) common stock between March 7, 

2016 and March 27, 2020, both dates inclusive (the “Class Period”), and otherwise be a Class Member as 

defined in the Notice. 

2. The submission of a Proof of Claim does not ensure that your claim will be upheld or that you 

will share in any recovery. All claims are subject to verification and investigation. You may be requested 

to provide further information. 

3. All claims must be made by persons or entities who were beneficial owners (as opposed to record 

holders or nominees) of shares of RTI common stock. (As outlined in the Notice, brokerage firms, banks 

and other nominees are requested to transmit copies of the Notice to their present or former customers 

who were such beneficial owners. See Notice, Section VIII.) If RTI common stock was owned jointly, all 

joint owners must complete and sign the Proof of Claim. 

4. Executors, administrators, guardians, conservators and trustees may complete and sign the Proof 

of Claim on behalf of persons or entities represented by them, but they must identify such persons or 

entities and provide proof of their authority (e.g., powers of attorney or currently effective letters 

testamentary or letters of administration) to do so. 

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5. You must file a separate Proof of Claim for each differently named account or ownership, such as 

an individual account, an IRA account, a joint account, a custodial account, etc. Joint tenants, co-owners 

or UGMA custodians should file a single claim. Claimants who file one or more claims (e.g., one in 

Claimant’s name and one for an IRA or joint ownership) must identify the other claims filed. 

6. NOTICE REGARDING ELECTRONIC FILES: Certain claimants with large numbers of 

transactions may request, or may be requested, to submit information regarding their transactions in 

electronic files. To obtain the mandatory electronic filing requirements and file layout, you may email 

the Claims Administrator’s electronic filing department at info@_____.com. Any file not submitted in 

accordance with the required electronic filing format will be subject to rejection. No electronic files will 

be considered to have been properly submitted unless the Claims Administrator issues an email after 

processing your file with your claim number(s) and respective account information. Do not assume that 

your file has been received or processed until you receive this email. If you do not receive such an email 

within 10 days of your submission, you should contact the electronic filing department at 

info@_______.com to inquire about your file and confirm it was received and acceptable. 

7. There will be no Recognized Loss attributed to any RTI securities other than common stock. 

8. The date of purchase and/or sale of shares of RTI common stock is the “trade” date and not the 

“settlement” date. 

9. The first-in, first-out basis (“FIFO”) will be applied to both purchases and sales. 

10. The date of covering a “short sale” is deemed to be the date of purchase of RTI common stock; 

and the date of a “short sale” is deemed to be the date of sale of RTI common stock. Shares originally 

sold short will have a Recognized Loss of zero. 

11. Exercise of option contracts or the conversion of preferred stock into common stock will be 

considered to be purchases or sales of common stock as of the date of the exercise or conversion. Option 

premiums and the conversion price for preferred stock will be incorporated into the purchase/sale price of 

the common stock accordingly. 

12. The Court has reserved jurisdiction to allow, disallow or adjust the claim of any Settlement Class 

Member on equitable grounds. 

13. No cash payment will be made on a claim where the potential distribution is less than $20.00. 

14. You must attach to your Proof of Claim form copies of brokerage confirmations, monthly 

statements or other documentation of your transactions in RTI common stock in order for your claim to 

be valid. Failure to provide this documentation could delay verification of your claim or could result in 

rejection of your claim. 

If you have any questions or need additional Proofs of Claim, contact the Claims Administrator via the 

information set forth in Section A. You may make photocopies of this form. 

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Lowry v. RTI Surgical Holdings, Inc., et. al.

PROOF OF CLAIM 

Must be received by the Claims Administrator postmarked no later than _______, 2021. 

C. CLAIMANT IDENTIFICATION 

Please Type or Print 

_____________________________________________________________________________________

Beneficial Owner’s Name (as it appears on your brokerage statement) 

_____________________________________________________________________________________

Joint Beneficial Owner’s Name (as it appears on your brokerage statement) 

_____________________________________________________________________________________

Street Address 

_________________________ __________________ ______________ 

City State Zip Code 

______________________________________ _________________________________________ 

Foreign Province Foreign Country 

_____________________________________ or _____________________________________ 

Last Four Digits of Social Security Number Last Four Digits of Taxpayer Identification 

 Number 

 

Specify one of the following: 

Individual(s) _____ Corporation _____ IRA _____ UGMA Custodian _____ 

Partnership _____ Estate _____ Trust_____ Other: _________________________ 

 __________________ (Day) ______________(Evening) 

Area Code Telephone Number Area Code Telephone Number 

______________________________________ _________________________________ 

Facsimile Number E-Mail Address 

____________________________________________________________________________________ 

Record Owner’s Name and Address (if different from beneficial owner listed above) 

D. SCHEDULE OF TRANSACTIONS IN RTI COMMON STOCK 

1. State the total number RTI common stock held as of close of trading on March 6, 2016. If none, 

write “zero” or “0.” __________

2. Separately list each and every purchase of RTI common stock between March 7, 2016 through June 

25, 2020, inclusive, and provide the following information (must be documented): 

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Trade Date 

(list 

chronologically) 

Month/Day/Year 

Number of 

Shares 

Purchased 

Purchase / Acquisition Price 

Per Share 

Total Amount of Purchase 

(excluding commissions, 

taxes and other fees) 

3. Separately list each and every sale of RTI common stock between March 7, 2016 through June 25, 

2020, inclusive, and provide the following information (must be documented):

Trade Date 

(list 

chronologically) 

Month/Day/Year 

Number 

of Shares

Sold 

Sale Price Per Share 

Total Amount of Sale 

(excluding commissions, 

taxes and other fees) 

 

4. State the total number of RTI common stock owned at the close of trading on June 25, 2020, long 

or short (if none, enter “0”; if other than zero, must be documented): 

If you need additional space, attach the required information on separate, numbered 

sheets in the same format as above and print your name and last four digits of your Social 

Security or Taxpayer Identification Number at the top of each additional sheet. 

YOU MUST ALSO READ THE RELEASE AND SIGN THE CERTIFICATION BELOW. 

E. SUBMISSION TO JURISDICTION OF THE COURT 

By submitting this Proof of Claim and Release form, I/we, and every Class Member I/we represent, 

submit to the jurisdiction of the United States District Court for the Northern District of Illinois for 

purposes of this Action and the Settlement of the Action, as reflected in the Stipulation of Settlement. 

I/we further agree to be bound by the orders of the Court, agree that this Proof of Claim form, my/our 

status or the status of the Class Member(s) I/we represent as a Claimant and the allowable amount of this 

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claim will be subject to review and further inquiry, and that I/we will furnish such additional 

documentation with respect to this Proof of Claim as may be required. 

F. RELEASE 

By signing this Proof of Claim and Release form, and in consideration of the establishment of the Net 

Settlement Fund, as of the Effective Date thereof, the undersigned claimant (“Claimant”), on behalf of 

Claimant and Claimant’s heirs, executors, administrators, personal representatives, attorneys, agents, 

partners, successors and assigns, and any other person claiming (now or in the future) to have acted 

through or on behalf of them, hereby release and forever discharge all of the “Released Claims,” including 

“Unknown Claims,” against each of the “Released Persons.” 

“Released Claims” means any and all claims, demands, rights, causes of action or liabilities of every 

nature and description whatsoever, whether based in law or equity, on federal, state, local, statutory or 

common law, or any other law, rule or regulation, including both known and unknown claims, from the 

beginning of time until the date on which the Court enters final approval of the Settlement, the Action is 

dismissed, and all appeals, if any, have been exhausted and which have been or could have been asserted 

in any forum by Plaintiff or the Class, or any of them, or the successors or assigns of any other them, 

whether directly, indirectly, representatively or in any other capacity against any of the Released Persons, 

which arise out of, or related in any way, directly or indirectly, to the allegations, transactions, facts, events 

matters, occurrences, acts, representations or omissions involved, set forth, referred to, or that could have 

been asserted in this Action, including without limitations, claims for statutory or common law fraud, 

negligence, gross negligence, or breach of fiduciary duty, provided, however, that the claims to be released 

shall not include any release of the derivative claims asserted in In re RTI Surgical Derivative Litigation, 

Civil Action No. 20 C 03347 (MFK), pending in the U.S. District Court for the Northern District of 

Illinois. Expressly excluded from the definition of Released Claims are: (i) all claims of any Person who 

submits a request for exclusion from the Settlement, to the extent that the Court grants any such request; 

and (ii) all claims to enforce the terms of the Settlement. 

“Released Persons” means RTI Holdings, Inc., Surgalign Holdings, Inc. and their past or present 

subsidiaries, parents, affiliates, successors and predecessors, shareholders, creditors, officers, directors, 

employees, insurers, reinsurers, professional advisors, attorneys, agents, auditors, accountants, and any 

firm, trust, corporation or other entity in which it has a controlling interest; and Camille I. Farhat, Brian 

K. Hutchison, Jonathon M. Singer, Robert P. Jordheim and Johannes W. Louw, their legal representatives, 

heirs, successors in interest or assigns, or any person, firm, trust, corporation or other entity in which 

Camille I. Farhat, Brian K. Hutchison, Jonathon M. Singer, Robert P. Jordheim and Johannes W. Louw 

has a controlling interest. 

“Unknown Claims” means: (i) any claims that Plaintiff or any Class Member does not know or suspect 

to exist in his, her, or its favor at the time of the release of the Released Persons, which if known by him, 

her, or it, might have affected his, her, or its decision(s) with respect to the Settlement, including, but not 

limited to, the decision not to object to the Settlement, provided such claim arises out of or relates to the 

purchase, acquisition or sale of RTI Surgical Holdings, Inc. common stock; and (ii) Defendants’ Claims 

that Defendant does not know or expect to exist in his, her, or its favor, which if known by him, her, or it 

might have affected his, her, or its decision(s) with respect to the Settlement. With respect to any and all 

Released Claims and Released Defendants’ Claims, the Parties stipulate and agree that upon the Effective 

Date, the Parties shall expressly waive, and each of the Class Members shall be deemed to have waived 

and by operation of the Order and Judgment shall have waived, any and all provisions, rights, and benefits 

conferred by any law of any state or territory of the United States, or principle of common law that is 

similar, comparable, or equivalent to Cal. Civ. Code § 1542, which provides: 

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A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS WHICH THE CREDITOR DOES 

NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING 

THE RELEASE, WHICH IF KNOWN BY HIM OR HER MUST HAVE MATERIALLY AFFECTED 

HIS OR HER SETTLEMENT WITH THE DEBTOR. 

Plaintiff acknowledges, and the Class Members shall be deemed by operation of the Order and 

Judgment to have acknowledged, that the inclusion of “Unknown Claims” in the definitions of Released 

Claims and Released Defendants’ Claims was separately bargained for and a key element of the Settlement 

of which this release is a part. 

G. REPRESENTATIONS 

I/we acknowledge that I/we have read the Notice, and that pursuant thereto I/we file this claim to 

participate in the Settlement. 

I/we hereby warrant and represent that neither I/we, nor any person I/we represent, is a Defendant (as 

defined in the Stipulation of Settlement) with respect to any of the claims asserted in the Action, member 

of a Defendant’s family or their legal representative, heir, successor or assign, an entity in which any 

Defendant (or a combination of defendants) have or had a controlling interest, or a person or entity who 

has requested exclusion from the Class. 

I/we hereby warrant and represent that I am/we are authorized to execute and deliver this Proof of 

Claim and Release form. 

H. CERTIFICATION 

I/we certify that I am/we are not subject to backup withholding. (If you have been notified by the IRS 

that you are subject to backup withholding, strike out the previous sentence.) 

I/we declare and affirm under penalties of perjury that the foregoing information and the documents 

attached hereto, including the Social Security or Taxpayer Identification Number shown on this Proof of 

Claim, are true, correct and complete to the best of my/our knowledge, information and belief, and that 

this Proof of Claim was executed this ____ day of ________________, 2021 in 

________________________________________________________________ (City) (State/Country). 

 

 

 

Signature of Claimant 

 

 

 (Print your name here) 

 

 

Signature of Joint Claimant, if any 

 

 

(Print your name here) 

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Signature of person signing on behalf of Claimant 

 

 

 (Print your name here) 

 

 

Capacity of person signing on behalf of Claimant, 

if other than an individual (e.g., Executor, 

President, Custodian, etc.) 

ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT 

OF TIME. THANK YOU FOR YOUR PATIENCE. 

Reminder Checklist: 

1. Remember to sign the above Release and Certification. 

2. Remember to attach only copies of acceptable supporting documentation. Failure to provide all 

the acceptable documentation and transactions requested may result in the rejection of your claim 

in part or in full. 

3. Do not send originals of securities certificates. 

4. Keep copies of the completed claim form and documentation for your own records. 

5. The Claims Administrator will acknowledge the receipt of your Proof of Claim postcard within 

60 days of receipt. If you do not receive such acknowledgement within 60 days, please contact 

the Claims Administrator. Your claim is not deemed filed unless a postcard is received.

6. If your address changes in the future, or if these documents were sent to an old or incorrect 

address, please send us written notification of your new address. 

7. If you have any questions or concerns regarding your claim, please contact the Claims 

Administrator at: Lowry v. RTI Surgical Holdings, Inc., Claims Administrator, www.______.com 

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