WinCo Foods, LLC. U.S. District Court, District of Oregon Case No. 3:19-cv-02094 Settlement Claim Form If you are a Settlement Class Member and wish to receive a payment, your completed Claim Form must be postmarked on or before [ ], or submitted online at [website] on or before [ ]. Please read the full notice of this settlement (available at [website]) carefully before filling out this Claim Form. To be eligible to receive any benefits from the settlement obtained in this class action lawsuit, you must submit this completed Claim Form online or by mail: ONLINE: Visit [website] and submit your claim online. MAIL: [ADDRESS] PART ONE: CLAIMANT INFORMATION Provide your name and contact information below. It is your responsibility to notify the Settlement Administrator of any changes to your contact information after the submission of your Claim Form. FIRST NAME LAST NAME CURRENT STREET ADDRESS CURRENT CITY CURRENT STATE CURRENT ZIP CODE EMAIL ADDRESS To qualify for a cash payment, you must have purchased at least one certain non-grocery item from a WinCo store within the City of Portland, Oregon and paid a surcharge at least once on a certain non-grocery item between June 1, 2019 and May 8, 2022. Please provide the WinCo store address at which you claim you purchased a certain non-grocery item and paid a surcharge on this non-grocery item. STREET ADDRESS OF WINCO STORE YOU CLAIM YOU PURCHASED NON-GROCERY ITEMS AND WERE CHARGED A SURCHARGE CITY STATE ZIP CODE Please provide the approximate date you claim you purchased non-grocery items and paid a surcharge: Please provide a description of the non-grocery item(s) you purchased on the date provided above and paid a surcharge: POTENTIAL CASH PAYMENT*: You may be entitled to receive a cash payment of up to $200.00 if you purchased at least one certain non-grocery item from a WinCo store within the City of Portland and paid a surcharge at least once on a certain non-grocery item between June 1, 2019 and May 8, 2022. Please select a payment method: * The cash payments set out herein represent the maximum that you can receive under the settlement. The actual cash paid may be reduced depending on the aggregate total of claims submitted by all Settlement Class Members.
WinCo Foods, LLC. Xxxx Xxxxxxx IT Purchasing Specialist PO BOX 5796 Boise, ID 83705 P (000) 000-0000 Xxxx.xxxxxxx@xxxxxxxxxx.xxx Period of Performance: August 2016 - Current Description: Provide telecom equipment as needed per customers request and specifications. Multiple delivery locations. Value: $15,000.00 +/year
