To make a claim under the Settlement, you must complete this form. Your claim form must be submitted by February 16, 2018.
All information will be kept private. It will not be disclosed to anyone other than the Court, the Claim Administrator, and the parties in this case,
and will be used only for purposes of administering this Settlement.
This Settlement involves the following olive oil Products sold at Safeway retail stores in the United States:
For each Product bottle you purchased, you will receive:
*The Voucher and cash payment amounts will be $0.75 and $0.25, respectively, for Safeway Select Extra Virgin Olive Oil purchases between
August 1, 2015 and December 16, 2016. The amounts may be subject to other reductions if various settlement limits are reached. You will be sent
Voucher(s) unless you choose the cash option below. See the Settlement Notice for details.
If you want to make a claim for more than five Product purchases you must submit at least one of the following:
You can make a claim even if you do not submit Club Card information or store receipts. However, such claims will be limited to five Product
purchases, with a maximum payment of $7.50 in Vouchers or $2.50 in cash.
You will receive the Vouchers / cash payments only if the Court approves the Settlement. Please save a copy of this completed form and your store
receipts for your records.
I, or a member of my family is the owner or authorized user of the following Safeway Club Card(s): (Enter 10-digit telephone numbers linked to
Club Cards (if known))
Were any of these Safeway Club Cards registered to a different mailing address from the one you entered above?
Provide the other address where your Safeway Club Card may be registered.
Do you have any purchases of the Products that were not made with the above Safeway Club Accounts, which you have receipts for? If Yes, upload the receipts now.
Maximum file size: 30 mb
Allowed file types: .jpg, .jpeg, .tif, .tiff, .gif, .png, .pdf
Do you have any purchases you would like to claim, that were not made with the above Safeway Club Accounts, for which you do not have a receipt? If you are only making claims for the products shown in your Club Card records or in the store receipts you are attaching, select 'No'.
I purchased the following additional
Safeway Select Olive Oil Products at a Safeway retail store in the United States between May 23, 2010 and December 16, 2016. (See above for
definitions of Products):
Click Continue to review your claim before submitting.