Case 2:12-md-02311-SFC-RSW ECF No. 2114-8, PageID.38376 Filed 02/17/21 Page 1 of 5
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`Case 2:12-md-02311-SFC-RSW ECF No. 2114-8, PageID.38377 Filed 02/17/21 Page 2 of 5
`Case Name Administrator
`P.O. Box 404041
`Louisville, KY 40233-4041
`ICR
`
`Must Be Postmarked
`No Later Than
`July 12, 2018
`
`ILLINOIS STATE CRT ANTITRUST SETTLEMENT CLAIM FORM
`
`CLAIMANT INFORMATION
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`First Name
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`Primary Address
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`Primary Address Continued
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`City
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`M.I.
`
`Last Name
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`State
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`Zip Code
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`Foreign Province
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`Foreign Postal Code
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`Foreign Country Name/Abbreviation
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`Complete this Claim Form to receive payment from settlements totaling more than $36 million. Illinois consumers
`(individuals and businesses) that purchased televisions or monitors containing CRTs from a retailer or someone other
`than the manufacturer of the component CRT are eligible to receive a payment from the settlement funds. A CRT is a
`piece of technology used as displays (screens) in televisions and computer monitors. Before LCD, Plasma and LED
`display technologies became popular, CRTs were the main technology used for displays in these devices.
`You must answer the two Eligibility Questions and list the number of CRT televisions and/or monitors you purchased to
`submit a claim. Each eligible product must contain a CRT. The amount you could expect to receive per product is $20
`for each CRT television and $60 for each CRT monitor.
`Your recovery could be a smaller amount than the maximum because there is a limited amount of money in the
`Settlement Fund. The amount paid per product and the number of claims allowed per consumer will depend on
`the number of claims submitted on or before the deadline, which is July 12, 2018. Any claims filed after July 12,
`2018 will be considered for payment only if settlement funds remain after all valid claims filed by that date have been
`paid in full.
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`*ICRWONE*
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`FOR CLAIMS
`PROCESSING
`ONLY
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`OB
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`1
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`CB
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` DOC
` LC
` REV
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`Case 2:12-md-02311-SFC-RSW ECF No. 2114-8, PageID.38378 Filed 02/17/21 Page 3 of 5
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`Section 1: Eligibility Questions
`1.
`Did you or your business buy one or more CRT televisions or CRT monitors in Illinois for your own use and not
`for resale between March 1, 1995 and November 25, 2007?:
` Yes
` No
`At the time of this (these) purchase(s), did you reside in Illinois, or for businesses, were you incorporated in or
`2
`were your headquarters in Illinois?
` Yes
` No
`Section 2: Purchase Information
`If you answered “Yes” to both Eligibility Questions, you are eligible to file a claim by completing the form below.
`Enter the total number of CRT televisions and/or CRT monitors you or your business purchased between March 1, 1995
`and November 25, 2007, for your own use while residing in the state of Illinois. Please enter the total number of
`products purchased, not the amount paid for the products.
`Total number of CRT televisions:
`,
`(max recovery $20 per TV)
`,
`
`Total number of CRT monitors:
`(max recovery $60 per monitor)
`
`Incomplete or inaccurate claim forms submitted as placeholders to be completed later will not be valid.
`Proof of purchase is not required to submit a claim but may be required later to verify eligibility..
`Section 3: Personal Information
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`First Name
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`M.I.
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`Last Name
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`Entity Name (if filing on behalf of a business)
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`Person to Contact If There Are Questions Regarding This Claim
`Specify one of the following:
` Individual
` Business
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`Current Address (individual) or Headquarters Location (business)
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`City
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`Email Address (optional)
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`State
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`Zip Code
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`—
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`—
`Area code
`Telephone number (daytime)
`Individual: Provide the last 4 digits of your Social Security Number: X X X — X X —
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`Business: Provide your Federal Taxpayer Identification Number:
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`—
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`*ICRWTWO*
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`2
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`Case 2:12-md-02311-SFC-RSW ECF No. 2114-8, PageID.38379 Filed 02/17/21 Page 4 of 5
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`Section 4: Acknowledgment and Verification
`I (We) understand that this Claim Form and all communications with the Illinois State Attorney General’s Office
`may become public records under state law and that public records are subject to disclosure (except private personal
`information) in response to requests. Personal information of individuals (address, phone number, email address
`and Social Security number) is confidential and will not be publicly disclosed.
`I (We) declare that the above information, including quantity of CRT products purchased is correct, and:
`For individuals - I (we) purchased these CRT products for my (our) own use and not for resale and that at the time of the
`purchase(s) of all CRT televisions and/or CRT monitors claimed in this form, I (we) resided in Illinois;
`For businesses- (i) I am duly authorized by this business to make this verification; (ii) this business purchased its CRT
`products for its own use and not for resale, and, (iii) at the time of the purchase(s) of all CRT televisions and/or CRT
`monitors claimed in this form, check one or both of the options below, as applicable:
`___ its headquarters was located in Illinois; or
`___ it was incorporated in Illinois.
`For individuals, the name of the person signing this acknowledgement and verification must match the name listed in
`Section 3 (Personal Information). For businesses, the individual verifying the information must be a duly authorized
`officer of the business. Verification provided by anyone else will be treated as an unverified claim and invalidated.
`I (We) declare, under the penalty of perjury under the laws of the State of Illinois, that the information provided
`in this Claim Form is true and correct.
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`Signature
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`Print Name
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` Dated
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` Title (if you are filing out this form for a business)
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`*ICRWTHREE*
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`3
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`Case 2:12-md-02311-SFC-RSW ECF No. 2114-8, PageID.38380 Filed 02/17/21 Page 5 of 5
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`1.
`2.
`3.
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`4.
`5.
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`Reminder
`Complete all four parts of this Claim Form.
`Sign the Claim Form.
`Submit your Claim Form online or by mail postmarked no later than July 12, 2018, to:
`www.illinoiscrtsettlement.com
`or
`CRT ILLINOIS CLAIMS
`
`
`P.O. Box 404041
`
`
`Louisville, KY 40233-4041
`Keep a copy of the completed Claim Form for your records.
`Retain your proof-of-purchase documentation until your claim is closed. You will be notified if you are
`required to provide this documentation during the claim-verification process.
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`*ICRWFOUR*
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`4
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