I. DEVELOPER INFORMATION

Please provide all of the information requested below. You must notify the Settlement Administrator if any of the information changes after you submit this form.

Name of all applications you have distributed through the Google Play store:

+ Add Application

Google Play Developer Account ID(s):

+ Add Account ID

Google Application Developer Gaia_ID(s):

+ Add Gaia_ID

(If you have multiple Google Play Developer Account IDs, you must specify each of them above. You can find your Google Play Developer Account ID or IDs by logging in to the Google Play Console and navigating to the "Account details" page, which can be found on the navigation menu. You may only access one Developer Account at a time. To view your other Developer Account IDs, you can select a different account from the account picker, next to the "Support" icon on the top right corner of the Google Play Console.

* Required Fields

II. PAYMENT SELECTION & ATTESTATION

You have successfully requested a payment. Click here if you would like to choose a different payment method.

If you elect to receive a physical check, you will have six months to deposit the check from the date the check is issued. Funds that are not deposited within six months of issuance of the physical check will revert to the settlement fund and you will not receive a payment.

If you elect PayPal, Venmo, or a Virtual Prepaid Card but do not provide sufficient information to receive a payment through the selected method, the Settlement Administrator may attempt to contact you to obtain additional information or may send you a paper check to your mailing address, if available. If the Settlement Administrator is unable to contact you and unable to issue a paper check, then the funds will revert to the settlement fund and you will not receive a payment.

I declare under penalty of perjury under the laws of the United States of America that the information I provided on this Payment Selection Form is true and correct to the best of my knowledge and that I am the owner of the developer account(s) identified above or authorized to submit this Payment Selection Form on the owner’s behalf. I understand that this Payment Selection Form is subject to audit, review, and validation using all available information.

Your Payment Selection has been submitted successfully.

Please print this page for your records.

Your Payment Selection Details
Class ID:
Confirmation Code:
CLAIM INFORMATION
Developer Name
Company Name
Email Address
Current Street Address
City
State
Province
Zip Code
Postal Code
Country
Signature
Date

If you have any questions regarding your Payment Selection, please provide the Class ID listed above and email us at Info@GooglePlayDeveloperSettlement.com

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