CLAIM FORM

PART I. INSTRUCTIONS AND ACKNOWLEDGMENTS

This Claim Form is intended for class members who intend to make a claim in the matter of Paciucci et al. v. FCA Canada Inc., Superior Court of Quebec, Court File No. 500-06-000905-188.

The Court approved a settlement relating to alleged defects affecting the door handle and/or door locking mechanism of certain Fiat 500 vehicles that causes the door handles to jam and, in some cases, break or detach from the vehicle (the "Door Handle Issue").

You may submit a claim if you meet the following criteria:

• You purchased or leased a Fiat 500 vehicle, model years 2012 through 2019, in Quebec; AND
• Paid out-of-pocket costs to repair or replace a door handle or related door locking mechanism due to the Door Handle Issue.

The settlement provides that eligible class members may receive reimbursement for repair costs previously paid to address the Door Handle Issue, subject to the terms and conditions of the Settlement Agreement.

If your vehicle is currently experiencing the Door Handle Issue, you should bring your Fiat 500 to an FCA Dealer for an inspection. The FCA Dealer will determine whether your vehicle is affected by the Door Handle Issue and whether it is eligible for repair at no cost to you.

If you previously paid out-of-pocket costs to repair or replace a door handle or related door locking mechanism due to the Door Handle Issue, you may also submit a claim for reimbursement in accordance with the Settlement Agreement.

Required Information

To submit a claim for reimbursement of out-of-pocket costs, you must provide the following information:

• Your Vehicle Identification Number (VIN);
• Your current contact information;
• The approximate date (month and year) when the Door Handle Issue first occurred;
• Documentation demonstrating both that (i) a repair was performed to correct the Door Handle Issue; AND (ii) that you paid for the repair.

If you cannot provide the information listed above or the documentation showing that a repair was performed and that you paid for it, you must instead provide the following additional information:

• The location where the repair was performed;
• The approximate date (month and year) of the repair;
• Confirmation of the specific door handle that was affected.

Payment of Claims

Approved claims will be paid by either Interac e-Transfer (sent by email) or by physical cheque (sent by mail), based on the payment method you select below.

Compensation Structure

Valid and approved claims will be reimbursed for the costs of parts, labour, and taxes incurred for the repair or replacement of the door handle resulting from the Door Handle Issue. There is no maximum amount per repair, nor is there a limit on the number of repairs a member can claim. Pursuant to Quebec law, an automatic deduction will be applied to each payment and remitted to the Fonds d'Aide aux Actions Collectives (2% for claims under $2,000, 5% for claims between $2,000-$5,000, and 10% for claims over $5,000).

Incomplete claim forms or claims submitted without sufficient documentation may be rejected or delayed.

Claim Deadline

Your completed Claim Form and all Supporting Documentation must be submitted no later than June 11, 2027, at 11:59 PM Eastern Time.

Claims received after the deadline will not be eligible for compensation.

Review of Claims

All claims will be reviewed by the Claims Administrator appointed by the Court. The claims administrator may:

• verify the information provided in this claim form;
• request that you provide additional documentation;
• approve, partially approve, or reject claims in accordance with the Settlement Agreement.

Submission of this claim form does not guarantee that compensation will be awarded.