Nasal Ease Settlement Claims Administrator
c/o CPT Group, Inc.
16630 Aston
Irvine, CA 92606

Hoover v. Hi‐Tech Pharmacal Co., Inc.

Case No. EDCV 13‐00097 JGB (OPx)

CLAIM FORM INSTRUCTIONS

In order for you to qualify to receive payments related to Hoover v. Hi-Tech Pharmacal Co., Inc as described in the Notice of this Settlement (the “Class Notice”), you must complete a Claim Form either in writing or electronically on the Settlement Website and may need to provide certain requested documentation to substantiate your claim.

REQUIREMENTS FOR FILING A CLAIM FORM

Your claim will be considered only upon compliance with all of the following conditions:

  1. This Claim Form only relates to purchases of Nasal Ease made in the United States between April 1, 2010 and February 25, 2014. Do not complete this Claim Form if you did not make a qualifying purchase of Nasal Ease.
  2. You may submit only one Claim Form, and two people cannot submit Claim Forms for the same qualifying purchase of Nasal Ease. All Claim Forms must be submitted by February 25, 2014.
  3. You must accurately complete all required portions of the attached Claim Form.
  4. You must sign this Claim Form, which includes the Certification Under Penalty of Perjury.

CLAIMANT INFORMATION

All of the information below is required, including a receipt, where available, for each purchase that you claim. If you do not provide all of the information below, your claim may be denied.

  All of the following information must be provided:
Claimant Name:  
Street Address:  
City:  
State:  
Zip Code:  
Phone Number:
Email:

You must provide the information in the table below for each purchase of Nasal Ease. If applicable, you must provide a receipt for each purchase you list below. If you cannot provide a receipt for a particular purchase, you may still submit your claim, as detailed below. If you do not provide all of the information below, your claim may be denied. If more space is needed, you may use a separate sheet to list any additional purchases and attach the sheet to this claim form.

QUALIFYING PURCHASES OF NASAL EASE
Date Of Purchase
(MM/DD/YYYY)
Purchase Price Store Name Store Location
(City, State)
Receipt
Yes/No

PROOF OF PURCHASE (Receipts)

Complete this claim form online, then print and mail the completed claim form along with your receipt(s) to: Nasal Ease Settlement Claims Administrator, 16630 Aston, Irvine, CA 92606. You will be reimbursed for your qualifying purchases of Nasal Ease in the amount shown on the receipt.

NO PROOF OF PURCHASE

If you do not have a receipt, you may submit a claim for Nasal Ease that you purchased by completing the Claim Information table above to the best of your knowledge. Then print and mail the completed claim form to: Nasal Ease Settlement Claims Administrator, 16630 Aston, Irvine, CA 92606. Non-proof-of-purchase claims will be processed after claims that are submitted with a receipt. Non-proof of purchase claims are eligible for a payment of $5.00 per purchase and are subject to a limit of $15.00 per household.

CERTIFICATION UNDER PENALTY OF PERJURY

I hereby certify under penalty of perjury, as follows:

  1. All of the information on this Claim Form is true and correct;
  2. If I have proof of a qualifying purchase of Nasal Ease that I have listed on this Claim Form, I am providing such proof with the submission of this Claim Form. If I do not have a receipt for a qualifying purchase listed on this Claim Form, I certify that I purchased the Nasal Ease for which I submit the claim.
  3. I understand that the Nasal Ease Settlement Claims Administrator may contact me to verify any of the information that I have provided on this Claim Form or to verify any of the proofs of purchase that I have submitted with this Claim Form; and
  4. I understand that the decision of the Nasal Ease Settlement Claims Administrator is final and binding on me.


Signature

Date



Print Name
Claim ID: 7270

Administrator: (888) 699‐8593