Moore v. Kimberly-Clark Worldwide, Inc.
In the Circuit Court for the 20th Judicial Circuit, County of St. Clair, State of Illinois
Settlement Claim Form
If you are a Class Member and wish to receive a payment, your completed Claim Form must be
submitted on or before August 18, 2020.
Please read the Notice carefully before filling out and submitting this Claim Form.
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.
District of Columbia
PART TWO: PURCHASE INFORMATION
To qualify for a cash benefit, you must have purchased one or more of the following products (“Subject Products”) from March 8, 2013 through November 19, 2019:
U by Kotex® Tampons, including: U by Kotex® Sleek® Tampons, U by Kotex® Fitness® Tampons, U by Kotex® Click® Tampons, and U by Kotex® Security® Tampons in Regular, Super, and Super-Plus Absorbency.
TOTAL NUMBER OF SUBJECT PRODUCTS
total number of of the Subject Products you purchased between March 8, 2013 and November 19, 2019: boxes
If claiming more than 5 boxes, you must submit proof of purchase documentation to support the number of boxes claimed. (Select "Choose File" then "Upload." You may submit more than one file.)
: You may be entitled to receive a POTENTIAL BENEFIT* $6.00 cash benefit for every box of the Subject Products you purchased between March 8, 2013 and November 19, 2019, up to a maximum of $30.00 without Proof of Purchase. You may receive a full refund in cash benefits based on the total retail value of the Subject Products if you submit Proof of Purchase, such as receipts, establishing each purchase during the Class Period. Packaging, including bar codes or UPCs, shall constitute Proof of Purchase only if the Subject Product(s) claimed to have been purchased can be identified from the packaging submitted.**
The cash will be sent in the form of a check.
* The benefits set out herein represent the maximum that you can receive under the Settlement. The actual benefit may be reduced depending on the aggregate total of claims submitted by all Class Members.
**Failure to include Proof of Purchase for cash claims in excess of $30.00 will result in the claim being reduced to $30.00 in cash. Submission of false or fraudulent information may result in the claim being rejected in its entirety.
PART THREE: ATTESTATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury under the laws of the United States of America that I purchased the products listed above between March 8, 2013 and November 19, 2019 and that all of the information on this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review.
CLAIM FORM REMINDER CHECKLIST
Before submitting this Claim Form, please make sure you:
Complete all fields in the Claimant Information section in Part One of this Claim Form.
total number of of the Subject Products you purchased between March 8, 2013 and November 19, 2019 in Part Two of this Claim Form. boxes Indicate whether you are including Proof of Purchase documentation, and if so, upload all such documentation.
Sign the Attestation under penalty of perjury in Part Three of this Claim Form. You must sign the Attestation in order to be eligible to receive settlement benefits.
Note that after successful submission and our receipt of your Claim Form, a message will display on your screen confirming receipt and the assigned claim number. Note that you will
not receive a separate email to confirm Claim Form receipt.