Patora v. Tarte, Inc.

Case No. 7:18-cv-11760

United States District Court for the Southern District of New York

Settlement Class Members who seek payment from the Settlement must complete and return this Claim Form. Claim Forms can be completed online at the Settlement Website, www.HPNsettlement.com, or can be completed and mailed to the Settlement Administrator at 1650 Arch Street, Suite 2210, Philadelphia, PA 19103. Claim Forms submitted by mail must be POSTMARKED OR SUBMITTED ONLINE NO LATER THAN JANUARY 21, 2020 at 11:59 pm, eastern time or they will be rejected.

Before you complete and submit this Claim Form by mail or online, you should read and be familiar with the Class Notice (the “Notice”) and the Settlement Agreement available at www.HPNsettlement.com. Defined terms (with initial capital letters) used in these General Instructions have the same meaning as set forth in the Notice and Settlement Agreement. By submitting this Claim Form, you acknowledge that you have read and understand the Notice, and you agree to the Release included as a material term of the Settlement Agreement.

If you fail to submit a timely Claim Form, your claim will be rejected and you will be precluded from any recovery from the Settlement Fund. If you are a member of the Settlement Class and you do not timely and validly seek exclusion from the Settlement Class, you will be bound by any judgment entered by the Court approving the Settlement even if you do not submit a Claim Form. To receive the most current information and regular updates, please visit the Settlement Website at www.HPNsettlement.com. You will also be able to submit your claim on the Settlement Website.

SECTION A: Claimant Information

SECTION B: For Each Product you have purchased during the Class Period, you may choose to fill out sections B1 or B2 (but not both), and you may also choose to fill out section C. However, you may not include the same purchases in more than one section. Completing Section B2 allows you to submit claims for up to ten (10) Products, but requires that you provide more information than in Section B1, which allows you to submit claims for up to five (5) Products.

SECTION B1: Include in Section B1 of this Claim Form the type(s), number of Products purchased and approximate dates of purchase. You may claim up to five (5) Products in this section. If you claim products in this section, you may not claim products in Section B2. You may also claim additional Products in Section C (with proof of purchase) but you may not include the same purchases in more than one section.

SECTION B2: Include in Section B2 of this Claim Form the type(s), number of Products purchased, retailer purchased from and location of purchase, approximate dates of purchase and satisfaction with the Product. You may claim up to ten (10) Products total under this Section. If you claim products in this section, you may not claim products in Section B1. You may also claim additional Products in Section C (with proof of purchase) but you may not include the same purchases in more than one section.

SECTION C: Include in Section C of this Claim Form purchases of Products you made during the Class Period for which you have retained proof of purchase. Proof of purchase means a receipt or other documentation reasonably establishing the fact of purchase, such as a loyalty/membership card print-out, or picture of UPC code for each eligible purchased product during the Settlement Class Period.

SECTION D: Certification Under Penalty of Perjury

Claim Form Reminder Checklist
Before Submitting this Claim Form, please make sure you:

  1. Complete all fields in Section A of this Claims Form.
  2. Complete Sections B and C to report the products you purchased. You may choose Section B1 or B2, but not both. Do not include the same purchases in more than one section.
  3. YOU MUST sign the certification under penalty of perjury in Section D of this Claim Form.
SECTION A. Claimant Information

It is your responsibility to notify the Claims Administrator of any changes to your contact information after the submission of your Claim Form.

* Required Fields
SECTION B. Purchase Information

Complete this section for any purchased Products for which you do not have Proof of Purchase. You may complete Section B1 or B2 but not both. Completing Section B2 allows you to submit claims for up to ten (10) Products, but requires that you provide more information than in Section B1, which allows you to submit claims for up to five (5) Products. You may also complete Section C, but may not include the same purchases in more than one section.

Section B1

The actual benefit you will receive will depend upon, among other things, how many Settlement Class Members submit a timely and complete claim form. You may receive $5.00 per unit, or more or less, depending upon how many claims are actually submitted, for up to five (5) units claimed in this section.

1. Please provide the following information regarding your purchase of up to five (5) of the Products:

# Approx. Date Purchased
(Month & Year)
Identify Which Product You Purchased
1
2
3
4
5
Section B2

The actual benefit you will receive will depend upon, among other things, how many Settlement Class Members submit a timely and complete claim form. You may receive $5.00 per unit, or more or less depending upon how many claims are actually submitted, for up to ten (10) units claimed in this section. You may complete Section B1 or B2 but not both. You may also complete Section C, but do not include the same purchases in more than one section.

1. Please provide the following information regarding your purchase of up to ten (10) of the Products:

# Approx. Date Purchased
(Month & Year)
Product You Purchased Quantity Retailer Where Purchased Location of Retailer Where Purchased Satisfaction (1-5, 5 being extremely satisfied)
1
2
3
4
5
6
7
8
9
10

2. Please identify the reason(s) you purchased the product (check all that apply):

Price:
Quality:
Ingredients:
Design:
Other:
SECTION C. Proof of Purchase

Complete this entire Claim Form and attach proof of purchase for the Products. You may receive a full refund for each unit, or more or less depending upon how many claims are actually submitted. Proof of purchase means a receipt or other documentation reasonably establishing proof of purchase for the Products purchased during the Settlement Class Period in the United States. You may complete either Section B1 or B2 in addition to this Section C, but may not include the same purchases in more than one section.

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded. Max file size: 20Mb

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    SECTION D. Certification Under Penalty of Perjury and Submission to Jurisdiction

    By signing below, you are submitting to the jurisdiction of the United States District Court for the Southern District of New York, and are agreeing to the terms of the Release set forth in the Settlement Agreement.

    I declare under penalty of perjury under the laws of the United States and the state where this Claim Form is signed that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below.

    I understand that all information provided on this Claim Form is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my Claim will be considered complete and valid.

    Your Claim Form has been submitted successfully.

    HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and send your documents with your Submitted Claim ID to the Settlement Administrator by email to: info@HPNSettlement.com.

    Please print this page for your records.

    Your Claim Details

    Submitted Claim ID:
    CLAIM INFORMATION
    First Name
    Middle Initial
    Last Name
    Street Address
    Street Address 2
    City
    State
    Zip Code
    Email Address
    Phone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at info@HPNSettlement.com