We-Vibe Claim Form printable pdf download

We-Vibe Claim Form

*3094300000000*

Class Member ID: 3094300000000

MUST BE SUBMITTED

For Office Use Only

ONLINE OR

POSTMARKED

N.P., et. al. v. Standard Innovation Corp.,

NO LATER THAN

d/b/a We-Vibe, No. 1:16-cv-8655

JULY 20, 2017

CLAIM FORM

Instructions. Fill out each section of this form and sign where indicated.

Name:

First Name

M.I.

Last Name

Street Address:

City:

___ ___ ___ ___

State: ____ ____

Zip Code:

___ - ___ ___ ___ ___

Email (optional):

Contact Phone #:

( ___ ___ ___ ) - ___ ___ ___ - ___ ___ ___ ___

(You may be contacted if further information is required.)

Class Member Affirmation: By submitting this Claim Form and checking the box(es) below, I declare that I

am a member of the Purchaser Class and/or the App Class and that the following statements are true (check

each box that applies; at least one box must be checked to receive payment; you may select both boxes if you

both statements apply):

I am an individual in the United States who purchased a Bluetooth-enabled We-Vibe

brand product

☐

before September 26, 2016.

™

I am an individual in the United States who downloaded the We-Connect

application and used it to

☐

control a We-Vibe

brand product before September 26, 2016.

A list of covered products is available on the Settlement Website.

*If you checked either box (or both), please provide the serial number of the device(s) below. (The serial

number is located on the box and device. You can visit the Settlement Website to see where the serial number is

located on the box and the device.)

Serial Number(s):

SIGNATURE:

PRINTED NAME:

DATED:

___ ___ / ___ ___ / ___ ___ ___ ___

Claim Forms must be submitted online or postmarked by July 20, 2017.

*30943*

*CF*

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We-Vibe Claim Form

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