HYDROXYCUT CLAIM FORM

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Hydroxycut Products Class Action Settlement

Daniel Garcia v. Iovate Health Sciences, U.S.A., Inc.

Case No. 1402915

Pending in the Santa Barbara Superior Court of the State of California

I: YOUR INFORMATION

(P.O. BOX ADDRESSES AND POSTAL OFFICE ADDRESSES ARE NOT VALID)
*I am submitting this claim form on behalf of someone else:
If yes, please provide an explanation for why you have the right to do so in the space provided below.

II: QUALIFYING HYDROXYCUT PRODUCT(S) YOU PURCHASED
If a quantity greater than '1' is selected, additional fields will appear below for you to fill in the Date Purchased and Total Purchase Price for each quantity.

Description Quantity You Purchased Date Purchased (MM/DD/YYYY) Total Purchase Price
(Less Savings & Tax)
III: INFORMATION ABOUT YOUR PURCHASE Where did you purchase the Hydroxycut Product(s) selected above?
(Please list & Separate by Comma(s))
Please note: Your claim will not be denied even if you cannot recall where you purchased the Product.
IV: PROOF OF PURCHASE Do you still have the original Purchase Receipt(s) for the Hydroxycut Product(s) identified above?

'IF YOU ANSWERED "YES", YOU ARE ENTITLED TO A FULL REFUND OF ALL PRODUCTS PURCHASED DURING THE CLASS PERIOD IF YOU SEND IN YOUR PURCHASE RECEIPT(S). IF YOU ANSWERED "NO", YOU ARE ENTITLED TO A MAXIMUM REIMBURSEMENT OF TWO BOTTLES OF HYDROXYCUT PURCHASED AT $14.00 PER BOTTLE.'

V. INSTRUCTIONS FOR MAKING A CLAIM TO MAKE A CLAIM FOR A MONETARY PAYMENT:
  • Make sure this form is filled out completely.
  • Sign and date the verification below (Section VI).
  • If you have your purchase receipt(s), submit it (or them) to the Settlement Administrator via this online claim form or mail them to Digital Settlement Group, LLC., P.O. Box 156, West Palm Beach, FL 33402.
  • You may submit a claim for full monetary payment for each Hydroxycut product you purchased and for which you have an original proof of purchase, up to no limit.
  • By submitting a Claim Form without a purchase receipt, you are representing under penalty of perjury that you no longer have a purchase receipt for the Hydroxycut Product(s) you bought and you are not aware of anyone else who is submitting a claim by asking for a refund based on the same Hydroxycut Product(s) purchased.
YOU MUST FOLLOW THE ABOVE INSTRUCTIONS EXACTLY OR YOUR CLAIM COULD BE DELAYED OR REJECTED The Settlement Administrator reserves the right to seek additional information to validate the claimant's claim form and/or disqualify an invalid claim. If you provide incomplete or inaccurate information, your claim may be denied.
VI. SWORN VERIFICATION STATEMENT
PLEASE READ THE BELOW CAREFULLY AS IT WILL AFFECT YOUR LEGAL RIGHTS.
I swear under penalty of perjury of the laws of California that the information I have supplied in this Claim Form is accurate, truthful, and complete in all respects. I understand that the above information will be reviewed and verified by a representative from the Settlement Administrator, and that I may be contacted for more information, if needed, in order to approve my claim. I understand that my claim will be reviewed by the Settlement Administrator and may be approved or denied.

WHAT HAPPENS NEXT?

Your claim form, if and when received, will be reviewed and processed by the Settlement Administrator to ensure that you are eligible for a monetary payment. If you are an Approved Claimant, your payment will be processed in a reasonable amount of time, as approved by the Court. Payment checks will be delivered by mail to the address you supplied.

IT IS YOUR RESPONSIBILITY TO SEND THE SETTLEMENT ADMINISTRATOR YOUR NEW CONTACT INFORMATION IF IT CHANGES TO ENSURE RECEIPT OF FURTHER NOTICES AND YOUR SETTLEMENT CHECK