Download claim form - Starbucks Coffee Company

In Re Starbucks Consumer Litigation
Western District of Washington, No. 2:11-cv-01985-MJP
CLAIM FORM
You must complete ALL fields below for your claim to be considered. The deadline to mail this form is
December 23, 2013.1 You must mail this form, postage prepaid, to:
Simpluris, Inc.
P.O. Box 26170
Santa Ana, CA 92799
Your Name:
Your Email Address:
Your Postal Mailing Address:
Your Telephone Number:
I purchased scooped coffee beans in amounts less than one pound at a time from a Starbucks store in the United
States between December 9, 2007 and November 7, 2011. Specifically, [YOU MUST COMPLETE OPTION A OR B, BUT
NOT BOTH, BELOW]:
OPTION A: Attached are receipts of my purchases. I made these purchases. I would like to receive
my payment [CHECK ONE]:
In a Starbucks gift card, or
In a check made out to the name above.
OPTION B: I do not have receipts, but I swear or affirm under penalty of perjury under the laws of the
United States of America that I purchased scooped coffee beans in amounts less than one pound at a
time as follows [COMPLETE THE BLANKS BELOW]:

I made these purchases ___________________ times between December 9, 2007 and
November 7, 2011.

I made these purchases in [LIST CITIES]:

I made these purchases on [LIST APPROXIMATE DATE(S), IF POSSIBLE]:
I swear or affirm under penalty of perjury under the laws of the United States of America that all of the
information I provide above is true and correct.
Signature: __________________________________________________________
Signed in
on
[CITY, STATE]
1
[DATE]
The deadline to submit this Claim Form may be extended if the court does not enter judgment at the Fairness Hearing or if
someone timely appeals that judgment. Please check the Settlement Website
(www.starbucks.com/scoopedcoffeesettlement) for the latest information.
LEGAL25449893.2