Common use of CERTIFICATION STATEMENT Clause in Contracts

CERTIFICATION STATEMENT. CERTIFICATION STATEMENT (Please note that you will not be eligible to receive any settlement benefit unless you sign and date this statement): I affirm that all information provided in Part One of this Claim Form is true and accurate. Signature Date Phone Number Print Name E-Mail Address EXHIBIT B(1) – GENERIC CLAIM FORM IF YOU SELECTED # 1 OR # 2 AS YOUR SETTLEMENT BENEFIT IN SECTION C ABOVE, STOP HERE AND SUBMIT ONLY PAGES 3 AND 4 OF THIS CLAIM FORM WITH ANY REQUIRED DOCUMENTATION. PROCEED TO PART TWO ON THE NEXT PAGE ONLY IF YOU SELECTED SETTLEMENT BENEFIT # 3 IN SECTION C ABOVE FOR REIMBURSEMENT OF OUT-OF-POCKET-EXPENSES. ELX -GN PART TWO REIMBURSEMENT OF EXPENSES FORM Electrolux Front Load Washing Machine Class Action Settlement Claim Form -- PART TWO PART TWO – REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES Please complete and return Part Two in addition to Part One if you are seeking reimbursement for documented out-of-pocket expenses you incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent (more than one time) mold, mildew and/or Odor Issues inside your Class Washer. Otherwise, complete Part One only. If you are eligible for and wish to make a claim for a cash reimbursement payment for out-of-pocket expenses incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent mold, mildew and/or Odor Issues inside your Washer, you must complete this Part Two of the Claim Form and Electrolux will reimburse you up to $500 of your documented out- of-pocket expenses incurred for service, replacement, and/or damaged garments or fabrics (reimbursement for damaged garments and fabrics also is subject to a $150 sub-limit that counts against the $500 aggregate limit for all reimbursement expenses).

CERTIFICATION STATEMENT. CERTIFICATION STATEMENT (Please note that you will not be eligible to receive any settlement benefit unless you sign and date this statement): I affirm that all information provided in Part One of this Claim Form is true and accurate. Signature Date Phone Number Print Name E-Mail Address EXHIBIT B(1) – GENERIC CLAIM FORM IF YOU SELECTED # 1 OR # 2 AS YOUR SETTLEMENT BENEFIT IN SECTION C ABOVE, STOP HERE AND SUBMIT ONLY PAGES 3 AND 4 OF THIS CLAIM FORM WITH ANY REQUIRED DOCUMENTATION. PROCEED TO PART TWO ON THE NEXT PAGE ONLY IF YOU SELECTED SETTLEMENT BENEFIT # 3 IN SECTION C ABOVE FOR REIMBURSEMENT OF OUT-OF-POCKET-EXPENSES. ELX -GN PART TWO REIMBURSEMENT OF EXPENSES FORM Electrolux Front Load Washing Machine Class Action Settlement Claim Form -- PART TWO PART TWO – REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES Please complete and return Part Two in addition to Part One if you are seeking reimbursement for documented out-of-pocket expenses you incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent (more than one time) mold, mildew and/or Odor Issues inside your Class Washer. Otherwise, complete Part One only. If you are eligible for and wish to make a claim for a cash reimbursement payment for out-of-pocket expenses incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent mold, mildew and/or Odor Issues inside your Washer, you must complete this Part Two of the Claim Form and Electrolux will reimburse you up to $500 of your documented out- of-pocket expenses incurred for service, replacement, and/or damaged garments or fabrics (reimbursement for damaged garments and fabrics also is subject to a $150 sub-limit that counts against the $500 aggregate limit for all reimbursement expenses).

CERTIFICATION STATEMENT. CERTIFICATION STATEMENT (Please note that you will not be eligible to receive any settlement benefit unless you sign and date this statement): I affirm that all information provided in Part One of this Claim Form is true and accurate. Signature Date Print Name Phone Number Print Name E-Mail Address EXHIBIT B(1) – GENERIC CLAIM FORM IF YOU SELECTED # 1 OR # 2 AS YOUR SETTLEMENT BENEFIT IN SECTION C ABOVE, STOP HERE AND SUBMIT ONLY PAGES 3 AND 4 OF THIS CLAIM FORM WITH ANY REQUIRED DOCUMENTATIONFORM. PROCEED TO PART TWO ON THE NEXT PAGE ONLY IF YOU SELECTED SETTLEMENT BENEFIT # 3 IN SECTION C ABOVE FOR REIMBURSEMENT OF OUT-OF-POCKET-EXPENSES. ELX -GN Exhibit B(2) – Electrolux Settlement Agreement ELX-PQ PART TWO REIMBURSEMENT OF EXPENSES FORM Electrolux Front Load Washing Machine Class Action Settlement Claim Form -- PART TWO PART TWO – — REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES Please complete and return Part Two in addition to Part One if you are seeking reimbursement for documented out-out- of-pocket expenses you incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent (more than one time) mold, mildew and/or Odor Issues (defined in Settlement Agreement and on website) inside your Class Washer. Otherwise, complete Part One only. If you are eligible for and wish to make a claim for a cash reimbursement payment for out-of-pocket expenses incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent mold, mildew and/or Odor Issues inside your Class Washer, you must complete this Part Two of the Claim Form and Electrolux will reimburse you up to $500 of your documented out- out-of-pocket expenses incurred for service, replacement, and/or damaged garments or fabrics (reimbursement for damaged garments and fabrics also is subject to a $150 sub-limit that counts against the $500 aggregate limit for all reimbursement expenses).

CERTIFICATION STATEMENT. CERTIFICATION STATEMENT (Please note that you will not be eligible to receive any settlement benefit unless you sign and date this statement): I affirm that all information provided in Part One of this Claim Form is true and accurate. Signature Date Phone Number Print Name E-Mail Address EXHIBIT B(1) – GENERIC CLAIM FORM IF YOU SELECTED # 1 OR # 2 AS YOUR SETTLEMENT BENEFIT IN SECTION C ABOVE, STOP HERE AND SUBMIT ONLY PAGES 3 AND 4 OF THIS CLAIM FORM WITH ANY REQUIRED DOCUMENTATION. PROCEED TO PART TWO ON THE NEXT PAGE ONLY IF YOU SELECTED SETTLEMENT BENEFIT # 3 IN SECTION C ABOVE FOR REIMBURSEMENT OF OUT-OF-POCKET-EXPENSES. Exhibit B(3) – Electrolux Settlement Agreement ELX -GN -ID PART TWO REIMBURSEMENT OF EXPENSES FORM Electrolux Front Load Washing Machine Class Action Settlement Claim Form -- PART TWO PART TWO – REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES Please complete and return Part Two in addition to Part One if you are seeking reimbursement for documented out-of-pocket expenses you incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent (more than one time) mold, mildew and/or Odor Issues inside your Class Washer. Otherwise, complete Part One only. If you are eligible for and wish to make a claim for a cash reimbursement payment for out-of-pocket expenses incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent mold, mildew and/or Odor Issues inside your Washer, you must complete this Part Two of the Claim Form and Electrolux will reimburse you up to $500 of your documented out- out-of-pocket expenses incurred for service, replacement, and/or damaged garments or fabrics (reimbursement for damaged garments and fabrics also is subject to a $150 sub-limit that counts against the $500 aggregate limit for all reimbursement expenses).

CERTIFICATION STATEMENT. CERTIFICATION STATEMENT (Please note that you will not be eligible to receive any settlement benefit unless you sign and date this statement): I affirm that all information provided in Part One of this Claim Form is true and accurate. Signature Date Print Name Phone Number Print Name E-Mail Address EXHIBIT B(1) – GENERIC CLAIM FORM IF YOU SELECTED # 1 OR # 2 AS YOUR SETTLEMENT BENEFIT IN SECTION C ABOVE, STOP HERE AND SUBMIT ONLY PAGES 3 AND 4 OF THIS CLAIM FORM WITH ANY REQUIRED DOCUMENTATIONFORM. PROCEED TO PART TWO ON THE NEXT PAGE ONLY IF YOU SELECTED SETTLEMENT BENEFIT # 3 IN SECTION C ABOVE FOR REIMBURSEMENT OF OUT-OF-POCKET-EXPENSES. ELX -GN ELX-PQ PART TWO REIMBURSEMENT OF EXPENSES FORM Electrolux Front Load Washing Machine Class Action Settlement Claim Form -- PART TWO PART TWO – — REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES Please complete and return Part Two in addition to Part One if you are seeking reimbursement for documented out-out- of-pocket expenses you incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent (more than one time) mold, mildew and/or Odor Issues (defined in Settlement Agreement and on website) inside your Class Washer. Otherwise, complete Part One only. If you are eligible for and wish to make a claim for a cash reimbursement payment for out-of-pocket expenses incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent mold, mildew and/or Odor Issues inside your Class Washer, you must complete this Part Two of the Claim Form and Electrolux will reimburse you up to $500 of your documented out- out-of-pocket expenses incurred for service, replacement, and/or damaged garments or fabrics (reimbursement for damaged garments and fabrics also is subject to a $150 sub-limit that counts against the $500 aggregate limit for all reimbursement expenses).

CERTIFICATION STATEMENT. CERTIFICATION STATEMENT (Please note that you will not be eligible to receive any settlement benefit unless you sign and date this statement): I affirm that all information provided in Part One of this Claim Form is true and accurate. Signature Date Phone Number Print Name E-Mail Address EXHIBIT B(1) – GENERIC CLAIM FORM IF YOU SELECTED # 1 OR # 2 AS YOUR SETTLEMENT BENEFIT IN SECTION C ABOVE, STOP HERE AND SUBMIT ONLY PAGES 3 AND 4 OF THIS CLAIM FORM WITH ANY REQUIRED DOCUMENTATION. PROCEED TO PART TWO ON THE NEXT PAGE ONLY IF YOU SELECTED SETTLEMENT BENEFIT # 3 IN SECTION C ABOVE FOR REIMBURSEMENT OF OUT-OF-POCKET-EXPENSES. ELX -GN -ID PART TWO REIMBURSEMENT OF EXPENSES FORM Electrolux Front Load Washing Machine Class Action Settlement Claim Form -- PART TWO PART TWO – REQUEST FOR REIMBURSEMENT OF OUT-OF-POCKET EXPENSES Please complete and return Part Two in addition to Part One if you are seeking reimbursement for documented out-of-pocket expenses you incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent (more than one time) mold, mildew and/or Odor Issues inside your Class Washer. Otherwise, complete Part One only. If you are eligible for and wish to make a claim for a cash reimbursement payment for out-of-pocket expenses incurred to service or replace your Class Washer or to replace damaged garments or fabrics due to persistent mold, mildew and/or Odor Issues inside your Washer, you must complete this Part Two of the Claim Form and Electrolux will reimburse you up to $500 of your documented out- out-of-pocket expenses incurred for service, replacement, and/or damaged garments or fabrics (reimbursement for damaged garments and fabrics also is subject to a $150 sub-limit that counts against the $500 aggregate limit for all reimbursement expenses).