CLAIM FORM-R
Baskin, et al. v. P.C. Richard & Son, LLC, et al.
Superior Court of New Jersey, Ocean County – Law Division
Docket No. OCN-L-000911-18

I. Your Information
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*Located on your mailed Notice*
Name*
Address:*
II. Please provide either:
(1) an original or copy of your customer receipt, OR
(2) an original or copy of your credit or debit card statement

You must provide proof in either one of the following two ways:

Option (1): You may attach an original or a copy of your customer receipt that contains the expiration date of your American Express (“AmEx”) credit or debit card and shows that you made a transaction at any P.C. Richard store at any time during the period November 12, 2015 through August 18, 2016. By completing this Claim Form-R you also confirm that you used your own personal AmEx card for the transaction.

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    OR

    Option (2): You may attach an original or a copy of your American Express (“AmEx”) credit or debit card statement showing that you made a transaction at any P.C. Richard store at any time during the period November 12, 2015 through August 18, 2016. By completing this Claim Form-R you also confirm that you used your own personal AmEx card for the transaction. Before providing your statement or copy of your statement, please redact (meaning you may white-out or mark-over) information contained in your credit or debit card statement to prevent it from showing things like your account numbers, your other purchases, etc. The only information that is required to show on your statement for purposes of making a claim under this Settlement is your name, address, and all of the details of your transaction from any P.C. Richard store, including the date and amount of your purchase.

    You may make only one claim regardless of whether you have made one or more than one eligible credit or debit card transaction. Accordingly, if you had more than one eligible transaction you only need to provide proof of either one receipt or one statement showing that you made one credit or debit card transaction at any P.C. Richard store at any time during the period November 12, 2015 through August 18, 2016.

    Drop files here or
    Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB, Max. files: 10.

      Payment Option

      Please select the Payment Option by which you would like to receive your payment and complete the steps as prompted.

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      Please verify your form.

      Signature*

      INSTRUCTIONS FOR THE CLAIM FORM-R
      Use this form only if you have NOT received written notice
      by postal mail or e-mail with a Claim Number or Notice Number

      I.Deadline For Returning Your Completed Claim Form-R

      If you have NOT received written notice by postal mail or e-mail with a Claim Number or Notice Number, then, to become an Eligible Settlement Class Member and obtain a payment you must complete and sign a valid Claim Form-R by no later than 11:59 p.m. Eastern Time on November 26, 2024.

      II.You Must Complete Section I Of The Claim Form

      You must complete Section I entitled “Your Information” by typing your information in the appropriate spaces. You must complete all of the spaces, except for your E-mail address which is optional.

      III.You Must Also Provide The Necessary Document With Your Claim Form

      As explained in Section II of the Claim Form, you must provide proof in either one of the following two ways:

      Option (1): You may attach an original or a copy of your customer receipt that contains the expiration date of your American Express (“AmEx”) credit or debit card and shows that you made a transaction at any P.C. Richard store at any time during the period November 12, 2015 through August 18, 2016. By completing this Claim Form-R you also confirm that you used your own personal AmEx card for the transaction.

      OR

      Option (2): You may attach an original or a copy of your American Express (“AmEx”) credit or debit card statement showing that you made a transaction at any P.C. Richard store at any time during the period November 12, 2015 through August 18, 2016. By completing this Claim Form-R you also confirm that you used your own personal AmEx card for the transaction. Before providing your statement or copy of your statement, please redact (meaning you may white-out or mark-over) information contained in your credit or debit card statement to prevent it from showing things like your account numbers, your other purchases, etc. The only information that is required to show on your statement for purposes of making a claim under this Settlement is your name, address, and all of the details of your transaction from any P.C. Richard store, including the date and amount of your purchase.

      You may make only one claim regardless of whether you have made one or more than one eligible credit or debit card transaction. Accordingly, if you had more than one eligible transaction you only need to provide proof of either one receipt or one statement showing that you made one credit or debit card transaction at any P.C. Richard store at any time during the period November 12, 2015 through August 18, 2016.

      IV.You Must Sign Using The Checkbox Provided In Section III Of The Claim Form

      You must also sign the Claim Form using the checkbox provided in Section III of the Claim Form.

      Questions? Call 1-888-226-2203