If you received a personalized notice in the mail with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

If you did not receive a notice you may mail an exclusion request to Don Roberto Jewelers Data Breach Settlement Administrator, Attn: Exclusion, P.O. Box 58220, Philadelphia, PA 19102.

Exclusion Form

I. CLASS MEMBER INFORMATION

* Required Fields

II. SIGNATURE

By signing below and submitting this form, I am requesting to be excluded from the Don Roberto Jewelers Data Breach Settlement Class.

Your Exclusion Form has been submitted successfully.

Please print this page for your records.

Your Exclusion Details
First Name
MI
Last Name
Street Address
Street Address 2
City
State
Province
Zip Code
Postal Code
Country
Email Address
Phone Number
Signature
Date
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