EXHIBIT E

Case: 1:20-cv-04699 Document #: 122-5 Filed: 02/25/21 Page 1 of 5 PageID #:2109
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UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF ILLINOIS

In Re: TikTok, Inc., Consumer Privacy Litigation, MDL No. 2948, 20-cv-4699 (N.D. Ill.)

CLAIM FORM INSTRUCTIONS

This claim form is for Settlement Class Members. The Settlement Class includes the following persons: All 

persons who reside in the United States who used the TikTok - Make Your Day video-sharing application (and/or

its Musical.ly predecessor) distributed in the U.S. (the “App”) prior to DATE of issuance of the Preliminary 

Approval Order. To receive a payment from the settlement, you must complete and submit this form.

How To Complete This Claim Form

1. There are two ways to submit this claim form to the Settlement Administrator: (a) online at the 

settlement website, www.tiktokdataprivacysettlement.com; or (b) by U.S. Mail sent to the following address: 

TikTok Data Privacy Settlement c/o Administrator, 1650 Arch Street, Suite 2210, Philadelphia, PA 19103. If 

you submit your claim by U.S. mail, make sure the completed and signed claim form are postmarked by 

DATE.

2. If you have any questions, please contact the Settlement Administrator by email at 

Info@TikTokDataPrivacySettlement.com or by telephone at 1-XXX-XXX-XXXX or send your question to 

the Settlement Administrator by U.S. mail using the address above.

3. You must notify the Settlement Administrator if your contact information changes after you send your 

Claim Form.

4. DEADLINE -- If you send in a Claim Form by U.S. mail, it must be postmarked by DATE. If you file a 

Claim Form online, then you must do so by 11:59 p.m. EST on DATE.

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Your claim must 

be postmarked by:

XXXXXXX

UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF 

ILLINOIS

In Re: TikTok, Inc., Consumer Privacy Litigation, MDL No. 2948, 20-

cv-4699 (N.D. Ill.)

Claim Form 

TIK

I. YOUR CONTACT INFORMATION

Provide your name and contact information below. You must notify the Settlement Administrator if your 

contact information changes after you submit this form. NOTE: For any class member who is a minor, the 

Claim form needs to be completed and signed by the Parent and/or Guardian of the Class Member.

Class Member’s First Name Class Member’s Last Name

Parent/Guardian First Name (for minors) Parent/Guardian Last Name (for minors)

 Street Address

 City State Zip Code

( ) -

 Current Phone Number Current Email Address

( ) -

 Mobile Phone Number Associated with your TikTok Account, If Any

 Email Address Associated with your TikTok Account, If Any

Please enter your

Notice ID #

(If you received a notice by email. If you do not have 

a notice ID, you may still be eligible to submit a 

claim.)

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II. CLASS MEMBER DETAILS

Do you currently reside in the United States?

Yes 

No 

Are you both (1) a resident of Illinois (2) who used the TikTok – Make Your Day 

video-sharing application (and/or its Musical.ly predecessor) to create videos while 

living in Illinois?

Yes 

No 

Did you use the TikTok - Make Your Day video-sharing application (and/or its 

Musical.ly predecessor) distributed in the U.S. prior to DATE of issuance of the 

Preliminary Approval Order?

Yes 

No 

Enter all usernames for TikTok accounts used 

by you or your minor child in the box to the 

right.

If you have additional TikTok accounts, 

please submit a list of your additional 

usernames with this Claim Form.

1. __________________________________

2. __________________________________

3. __________________________________

4. __________________________________

5. __________________________________

III. PAYMENT SELECTIONS

Please select one of the following payment options:

 PayPal - Enter your PayPal email address: __________________________________________________

 Venmo - Enter the mobile number associated with your Venmo account: __ __ __-__ __ __-__ __ __ __

 Virtual Prepaid Card – Enter the email address where you will receive the Virtual Prepaid Card:

 __________________________________________________

 Physical Check - Payment will be mailed to the address provided in Section I of this Claim Form.

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IV. VERIFICATION AND ATTESTATION UNDER OATH

By signing below and submitting this Claim Form, I hereby swear under penalty of perjury that the information 

provided in this Claim Form is, to the best of my knowledge, true and correct, and that I have not submitted 

another claim in connection with this Settlement and know of no other person having done so on my behalf.

___________________________________ Date: 

Your signature MM DD YYYY

___________________________________ 

Your name 

REMINDER CHECKLIST

1. Please make sure you answered all the questions on the claim form. Be sure to select only one payment option.

2. Please make sure that you signed and dated the claim form.

3. Please keep a copy of your completed claim form for your own records.

4. If you have any questions, please first refer to the settlement website, www.tiktokdataprivacysettlement.com. 

You may also contact the Settlement Administrator by calling the toll-free number, 1-XXX-XXX-XXXX, by 

email to Info@TikTokDataPrivacySettlement.com, or by writing via U.S. mail addressed to TikTok Data 

Privacy Settlement c/o Administrator, 1650 Arch Street, Suite 2210, Philadelphia, PA 19103.

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