Qualcomm Incorporated Securities Litigation

CLAIMANT INFORMATION

The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing.

Beneficial Owner’s Name:

Co-Beneficial Owner’s Name (if applicable):

Entity Name (if the Beneficial Owner is not an individual):

Representative or Custodian Name (if different from Beneficial Owner(s) listed above):

Address1 (street name and number): *

Address2 (apartment, unit or box number):

Country: *

City: *

State: *

Zip Code: *

Telephone Number (home): *

Telephone Number (work):

Email Address: (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim)

Account Number (account(s) through which the securities were traded)¹

Claimant Account Type: *

SCHEDULE OF TRANSACTIONS IN QUALCOMM COMMON STOCK

The only eligible security is Qualcomm Inc. (“Qualcomm”) common stock (Ticker: NASDAQ: QCOM, CUSIP: 747525103). Do not include information regarding any other securities. Please include proper documentation with your Claim Form as described in Part II – General Instructions, ¶ 6, above.

1. HOLDINGS AS OF FEBRUARY 1, 2012 – State the total number of shares of Qualcomm common stock held as of the opening of trading on February 1, 2012. (Must be documented.) If none, write “zero” or “0.”

Proof Provided

2. PURCHASES/ACQUISITIONS FROM FEBRUARY 1, 2012 THROUGH JANUARY 20, 2017 – – Separately list each and every purchase or acquisition (including free receipts) of Qualcomm common stock from February 1, 2012 through the close of trading on January 20, 2017. (Must be documented.)

Date of Purchase/ Acquisition (Month/Day/Year):

Number of Shares Purchased/Acquired:

Purchase/Acquisition Price Per Share:

Total Purchase/Acquisition Price:

Confirm Proof of Purchase Enclosed:

Must click Add Purchase to submit your transactions.

Date of Purchase/ Acquisition (List Chronologically) (Month/Day/Year)

Number of Shares Purchased/Acquired

Purchase/ Acquisition Price Per Share

Total Purchase/ Acquisition Price

Confirm Proof of Purchase Enclosed

Action

3. PURCHASES/ACQUISITIONS FROM JANUARY 21, 2017 THROUGH APRIL 20, 2017 – State the total number of shares of Qualcomm common stock purchased or acquired (including free receipts) from January 21, 2017 through the close of trading on April 20, 2017. If none, write “zero” or “0.”

4. SALES FROM FEBRUARY 1, 2012 THROUGH APRIL 20, 2017 – Separately list each and every sale or disposition (including free deliveries) of Qualcomm common stock from February 1, 2012 through the close of trading on April 20, 2017. (Must be documented.)

Date of Sale (List Chronologically) (Month/Day/Year):

Number of Shares Sold:

Sales Price Per Share:

Total Sales Price:

Confirm Proof of Sale Enclosed:

Must click Add Sale to submit your transactions.

Date of Sale (List Chronologically) (Month/Day/Year)

Number of Shares Sold

Sale Price Per Share

Total Sales Price (not deducting taxes, commissions, and fees)

Confirm Proof of Sale Enclosed

Action

5. HOLDINGS AS OF APRIL 20, 2017 – State the total number of shares of Qualcomm common stock held as of the close of trading on April 20, 2017. (Must be documented.) If none, write “zero” or “0.”

Proof Provided

UPLOAD SUPPORTING DOCUMENTS

All supporting documentation for your positions and transactions should be uploaded to this page prior to moving on to the next step in your online claim submission.

Please use the browse option, by clicking on “Select Files” in the box below, to upload your supporting documentation being submitted to verify all of your positions and transactions.

Select files

Files To Be Uploaded	Size	Action

PART IV – RELEASE OF CLAIMS AND SIGNATURE

YOU MUST ALSO READ THE RELEASE AND CERTIFICATION BELOW AND SIGN ON PAGE 8 OF THIS CLAIM FORM.

I (we) hereby acknowledge that, pursuant to the terms set forth in the Stipulation, without further action by anyone, upon the Effective Date of the Settlement, I (we), on behalf of myself (ourselves) and my (our) (the claimant(s)’) heirs, executors, administrators, predecessors, successors, and assigns, in their capacities as such, shall be deemed to have, and by operation of law and of the judgment shall have, fully, finally, and forever compromised, settled, released, resolved, relinquished, waived, and discharged each and every Released Plaintiffs’ Claim against Defendants and the other Defendants’ Releasees, and shall forever be barred and enjoined from prosecuting any or all of the Released Plaintiffs’ Claims against any of the Defendants’ Releasees.

CERTIFICATION

By signing and submitting this Claim Form, the claimant(s) or the person(s) who represent(s) the claimant(s) agree(s) to the release above and certifies (certify) as follows:

1. that I (we) have read and understand the contents of the Settlement Notice and this Claim Form, including the releases provided for in the Settlement and the terms of the Plan of Allocation;

2. that the claimant(s) is a (are) Class Member(s), as defined in the Settlement Notice, and is (are) not excluded by definition from the Class as set forth in the Settlement Notice;

3. that the claimant(s) did not submit a request for exclusion from the Class in connection with the previously disseminated Class Notice;

4. that I (we) own(ed) the Qualcomm common stock identified in the Claim Form and have not assigned the claim against any of the Defendants or any of the other Defendants’ Releasees to another, or that, in signing and submitting this Claim Form, I (we) have the authority to act on behalf of the owner(s) thereof;

5. that the claimant(s) has (have) not submitted any other claim covering the same purchases of Qualcomm common stock and knows (know) of no other person having done so on the claimant’s (claimants’) behalf;

6. that the claimant(s) submit(s) to the jurisdiction of the Court with respect to claimant’s (claimants’) claim and for purposes of enforcing the releases set forth herein;

7. that I (we) agree to furnish such additional information with respect to this Claim Form as Lead Counsel, the Claims Administrator, or the Court may require;

8. that the claimant(s) waive(s) the right to trial by jury, to the extent it exists, and agree(s) to the determination by the Court of the validity or amount of this Claim, and waive(s) any right of appeal or review with respect to such determination;

9. that I (we) acknowledge that the claimant(s) will be bound by and subject to the terms of any judgment(s) that may be entered in the Action; and

10. that the claimant(s) is (are) NOT subject to backup withholding under the provisions of Section 3406(a)(1)(C) of the Internal Revenue Code because (i) the claimant(s) is (are) exempt from backup withholding or (ii) the claimant(s) has (have) not been notified by the IRS that he, she, or it is subject to backup withholding as a result of a failure to report all interest or dividends or (iii) the IRS has notified the claimant(s) that he, she, or it is no longer subject to backup withholding. If the IRS has notified the claimant(s) that he, she, it, or they is (are) subject to backup withholding, please strike out the language in the preceding sentence indicating that the claim is not subject to backup withholding in the certification above .

UNDER THE PENALTIES OF PERJURY, I (WE) CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME (US) ON THIS CLAIM FORM IS TRUE, CORRECT, AND COMPLETE, AND THAT THE DOCUMENTS SUBMITTED HEREWITH ARE TRUE AND CORRECT COPIES OF WHAT THEY PURPORT TO BE

NOTE: If you have been notified by the I.R.S. that you are subject to backup withholding, please strike out the language that you are not subject to backup withholding in the certification above.

Signature of Claimant (if Beneficial Owner is an individual filing on his or her own behalf): *

Signature of joint Claimant, if any:

If the Claimant is other than an individual, or is not the person completing this form, the following also must be provided:

Signature of person signing on behalf of claimant:

Capacity of person signing on behalf of Claimant, if other than an individual, e.g., executor, president, trustee, custodian, etc. :

PART IV – RELEASE OF CLAIMS AND SIGNATURE YOU MUST ALSO READ THE RELEASE AND CERTIFICATION BELOW AND SIGN ON PAGE 8 OF THIS CLAIM FORM.

CERTIFICATION

PART IV – RELEASE OF CLAIMS AND SIGNATURE

YOU MUST ALSO READ THE RELEASE AND CERTIFICATION BELOW AND SIGN ON PAGE 8 OF THIS CLAIM FORM.