Cicciarella, et al. v Califia Farms LLC

Claim Form

CLAIMANT INFORMATION

PURCHASE INFORMATION OR DOCUMENTATION

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PURCHASE INFORMATION
CERTIFICATION

By submitting this claim, you acknowledge that you hold the Settlement Administrator harmless from any and all losses, claims, liabilities, damages, or suits arising out of or in connection with the issuance of any distribution payment in this matter, including those resulting from the submission of incorrect contact information or fraud.

Required

*Payment amounts will be reduced on a pro rata basis (equally proportioned) if the total amount of money claimed with proof of purchase is more than $2,000,000.00.

**Payment amounts will be reduced on a pro rata basis (equally proportioned) if the total amount of money claimed without proof of purchase is more than $1,000,000.00.