Please complete the form below and click "submit" to send the form or "reset" to erase and reenter all of the information contained in the form. If you need assistance in completing this form, please contact Alena McHale at amchale@qsclpc.com

IF YOU HAVE MORE THAN ONE ACCOUNT,
PLEASE COMPLETE ONE FORM FOR EACH ACCOUNT


SEC v. Cornerstone Prodigy Group, Inc., et al.; Cause No. 499-CV-0978-Y

OFFICIAL COURT- APPROVED CLAIM FORM

I, , declare that I have a claim against Cornerstone Prodigy Group, Inc., as follows:

 

Total amount I paid to Cornerstone:
(Include all amounts you paid whether by cash, check or credit card; Do not include roll over/ reinvestment amounts.)
Affiliate Program
Executive Net Profits
$
$
Less: Value of Products Purchased
$
$
Profit sharing payments I received from Cornerstone which actually cleared the bank
$
$

Amount received as a refund from credit card company
(If you received a refund from your credit card company complete the portion below.)
$
$
Referral payments received from Cornerstone which actually cleared the bank.
$
$
Commission payments received from Cornerstone which actually cleared the bank.
$
$

Any other payments received from Cornerstone
(for example - withdrawal of funds from the program)
$
$
Total amount due to me:
$
$
My full name is:
My complete address is:
My social security no. is.:
My phone number is:
Complete the following only if you received a refund of all or a portion of the money you paid to Cornerstone from a credit card company.
Name on Credit Card
Credit Card Number
Name of Credit Card Company
Amount of Refund $

If you received more than one refund, please detail each refund.

Additional information:
:

Contact Name:
Email Address:
Date you invested in Cornerstone/
and or Executive Net Profits: