DMCA Takedown Form All Fields are Required for a Claim. Contact Information First and Last Name Email Company Name Street Address City State Zip Phone Number Statement of Ownership Please submit your statement of exclusive ownership Identification of Work Please identify the infringing work, including full description of work and URL of location of work Statement of Infringment A statement you have a good-faith belief that use of the material in the manner complained of is not authorized by the copyright owner, its agent, or the law and no fair use provision applies. Statement of Truthfulness You state, under penalty of purgery, that all of the information above is truthful and accurate. Signify by typing YES. Electronic Signature As per the Electronic Signatures in Global and National Commerce Act (ESIGN), typing your FULL name below (first middle last), constitutes a legal signature.