Starbucks Coffee Company



In Re Starbucks Consumer LitigationWestern District of Washington, No. 2:11-cv-01985-MJPCLAIM FORMYou must complete ALL fields below for your claim to be considered. The deadline to mail this form is December 24, 2013. You must mail this form, postage prepaid, to:Simpluris, Inc.P.O. Box 26170Santa Ana, CA 92799Your 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]: FORMCHECKBOX OPTION A: Attached are receipts of my purchases. I made these purchases. I would like to receive my payment [Check One]: FORMCHECKBOX In a Starbucks gift card, or FORMCHECKBOX In a check made out to the name above. FORMCHECKBOX 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 FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? on FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????[City, State] [Date] ................
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