Claim Form - O-I Glass Settlement

Step 1 of 5 - Instructions

ClaimFormNo
O-I Glass ERISA Settlement
c/o Atticus Administration
PO Box 64053
Saint Paul, MN 55164
Email: O-IGlassERISASettlement@atticusadmin.com

FORMER PARTICIPANT CLAIM FORM

This Former Participant Claim Form is ONLY for Class Members who are Former Participants of the Owens-Illinois Long-Term Savings Plan or the Owens-Illinois Stock Purchase and Savings Program, or the beneficiaries or alternate payees of Former Participants (all of whom will be treated as Former Participants). A Former Participant is a Class Member who did not have an Active Account as of March 31, 2024.

This form must be completed, signed, and submitted via the Settlement Website or mailed with a postmark on or before July 25, 2024 to the Settlement Administrator in order for you to receive your share of the Settlement proceeds. Former Participants who do not complete and timely return this Claim Form will not receive any Settlement payment. Please review the instructions below carefully. If you have questions regarding this Claim Form, you may contact the Settlement Administrator as indicated below.
PART 1: INSTRUCTIONS FOR COMPLETING FORMER PARTICIPANT CLAIM FORM
1. Complete this Claim Form and keep a copy of all pages of your Former Participant Claim Form, including the first page with the address label, for your records.
2. Submit this completed Former Participant Claim Form postmarked on or before July 25, 2024.
  It is your responsibility to ensure the Settlement Administrator has timely received your Former Participant Claim Form.
3. Other Reminders:
  - You must provide date of birth, signature, and a completed Substitute IRS Form W-9, which is attached as part 5 to this form.
  - If you desire to do a rollover but you do not complete in full the rollover information in Part 4, below, payment will be made to you by check.
  - If you change your address after sending in your Former Participant Claim Form, please provide your new address to the Settlement Administrator.
  - Timing of Payments to Eligible Class Members. Please note that Settlement payments are subject to the Settlement Agreement's receiving final Court approval. If the Settlement Agreement is approved and if you are entitled to a Settlement payment under the terms of the Settlement, such payments will likely be distributed within approximately 90 days after the Court's final approval order due to the need to process and verify information for all Class Members who are entitled to a payment and to compute the amount of each payment. Payments may be further delayed if any appeals are filed.
4. Questions? If you have any questions about this Former Participant Claim Form, please call the Settlement Administrator at 1-800-484-3040. The Settlement Administrator will provide advice only regarding completing this form and will not provide financial, tax or other advice concerning the Settlement. You therefore may want to consult with your financial or tax advisor. Information about the status of the approval of the Settlement, the Settlement administration, and claim processing is available on this Settlement Website.
You are eligible to receive payment from a class action settlement. The Court has preliminarily approved the class settlement of Schaf, et al. v. O-I Glass, Inc., et al., Civil Action 3:22-cv-01240-JZ (N.D. Ohio). That Settlement provides allocation of monies to the individual accounts of persons who participated in the Owens-Illinois Long-Term Savings Plan or the Owens-Illinois Stock Purchase and Savings Program (the "Plans") at any time during the period from July 22, 2016, through March 5, 2024 ("Class Members") as defined in the Settlement Agreement. Class Members who are entitled to a distribution but who no longer had Active Accounts as of March 31, 2024, ("Former Participants") will receive their allocations in the form of a check or rollover if and only if they mail a valid Former Participant Claim Form postmarked on or before July 25, 2024 to the Settlement Administrator. For more information about the Settlement, please visit our FAQ Page or call 1-800-484-3040.

Because you are a Former Participant in the Plan, you must decide whether you want your payment (1) sent payable to you directly by check or (2) to be rolled over into another eligible retirement plan or into an individual retirement account ("IRA"). To make a payment election, please complete and submit or mail this Former Participant Claim Form postmarked on or before July 25, 2024, to the Settlement Administrator. If you do not indicate a payment election, your payment will be sent to you directly by check.

PART 2: PARTICIPANT INFORMATION
Claimant ID*
Name*
First Middle Initial Last
Mailing Address*
Street Address Address Line 2 City State Zip Code
Home Phone*
Work Phone or Cell Phone
Participant's Social Security Number*
This field is hidden when viewing the form
Participant's Social Security Number
Participant's Date of Birth*
Email Address*

PART 3: BENEFICIARY OR ALTERNATE PAYEE INFORMATION (IF APPLICABLE)
Surviving spouse
- Check here if you are the surviving spouse or other beneficiary for the Former Participant and the Former Participant is deceased. Documentation must be provided showing current authority of the representative to file on behalf of the deceased. Please complete the information below and then continue on to Parts 4 and 5.
Supporting Documentation
Drop files here or

Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB, Max. files: 20.
Alternate payee
- Check here if you are an alternate payee under a qualified domestic relations order (QDRO). The Settlement Administrator may contact you with further instructions. Please complete the information below and then continue on to Parts 4 and 5 on the next page.
Alternate Payee Name
First Middle Initial Last
Alternate Payee Social Security Number or Tax ID Number
This field is hidden when viewing the form
Alternate Payee Social Security Number or Tax ID Number
Alternate Payee Date of Birth
Alternate Payee Mailing Address
Street Address Address Line 2 City State Zip Code

PART 4: PAYMENT ELECTION
Payment election*
- Payment to Self – A check subject to mandatory federal and applicable state withholding tax will be mailed to your address on the previous page
- Direct Rollover to an Eligible Plan - If checked, you must complete the Rollover Information Section below
Rollover Information:
Account Type
- Government 457(b)
- 401(a)/401(k)
- 403(b)
- Direct Rollover to a Traditional IRA
- Direct Rollover to a Roth IRA (subject to ordinary income tax)
Company or Trustee’s Name (to whom the check should be made payable)
Company or Trustee’s Mailing Address
Street Address Address Line 2 City State Zip Code
Company/Trustee's Phone Number
Your Account Number

O-I Glass ERISA Settlement

Step 1 of 5 - Instructions