Mason v. Heel, Inc.

Case No. 12-cv-3056-GPC-KSC

U.S. District Court for the Southern District of California

Claim Form

Download a claim form (right-click and select Save As), or file electronically below.

You must complete this Claim Form in its entirety. This Claim Form only relates to qualifying purchases of homeopathic products manufactured or distributed by Heel and labeled “homeopathic” (a “Heel Homeopathic Product”). A qualifying purchase means you purchased the Heel Homeopathic Product between December 21, 2008 and the Opt-Out Date, as designated by the Court in its Preliminary Approval Order. Do not complete this Claim Form if you did not make a qualifying purchase of a Heel Homeopathic Product. All information requested on this Claim Form is required. Proof(s) of purchase is required only if you have proof (such as receipt or external packaging), for each purchase that you claim.

You may submit only one Claim Form, and two people cannot submit Claim Forms for the same
qualifying purchase of a Heel Homeopathic Product. All Claim Forms must be submitted no later than ninety (90) calendar days of the date the court enters the final judgment approving the settlement ('Claim-In Period'). The deadline is forecast to be no earlier than June 5, 2014. Failure to do so will result in a denial of your Claim.

1. Your Name and Address

First Name

Last Name

Email Address

Address

City

State

Zip

2. Claim Information

All of the information below is required. You must provide the information in the table below for each purchase of a Heel Homeopathic Product(s). (If additional space is needed, please submit using the paper claim form above.) If available, you must provide proof of each purchase you list below. If you cannot provide proof of a particular purchase, you may still submit your claim as detailed below. For each purchase that is the subject of a claim, there is a limit of up to $25.00 per Heel Homeopathic Product. For that reason, you must state the known or estimated purchase price. If you do not provide all of the information below, your claim may be denied.

Product Name Date of Purchase
(After
12/21/08)
Purchase
Price
Store Name & Location
(City / State)
Proof of
Purchase
(optional)
$
$
$
$
$
$
$
$
$
$

No Proof of Purchase

If you do not have a proof of purchase, you may submit a claim for Heel Homeopathic Product(s) you purchased by completing the Claim Information table above to the best of your knowledge and agreeing to the below Certification Under Penalty of Perjury. Non-proof-of-purchase claims will be processed after claims that are submitted with a proof of purchase. Non-proof of purchase claims are subject to a $100.00 per claimant limit, and may be reduced based on the number of claims received.

Proof of Purchase

If available, proof of purchase is required for each qualifying purchase of a Heel Homeopathic Product listed above. There is a limit of $150.00 per claimant for claims containing proof(s) of purchase.

3. Sign Your Claim Form

I hereby certify under penalty of perjury, as follows:

  • All of the information on this Claim Form is true and correct;
  • If I have proof of a qualifying purchase of any Heel Homeopathic Product(s) 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 proof of purchase for a qualifying purchase listed on this Claim Form, I certify that I purchased the product for which I submit the claim and I have estimated the purchase price in good faith.
  • I understand that the Claim 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
  • I understand that the decision of the Claim Administrator is final and binding on me.