Claim Form - Simonin v. WinCo Foods, LLC

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

Address 1

Address 2

City

State or Territory

Zip

Phone Number

Confirm Email

PART TWO: CLAIM INFORMATION

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.

Address

City

State or Territory

Zip Code

Please provide the approximate date you claim you purchased a non-grocery item and paid a surcharge:

Purchase Date

Please provide a description of the non-grocery item you purchased on the date provided above and paid a surcharge:

Item

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.

* The cash payments set out herein represent the maximum 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.

Please select a payment method:

Payment Options

You have successfully submitted your payment details.

PART THREE: ATTESTATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United States of America that: (i) I purchased at least one non-grocery item from a WinCo store located within the City of Portland, Oregon and paid a surcharge on a non-grocery item at least once between June 1, 2019 and May 8, 2022; and (ii) 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.

Signature

Date

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