Claim Form

If you are a Settlement Class Member and wish to receive a payment, your completed Claim Form must be postmarked on or before September 27, 2023, or submitted online on or before September 27, 2023.

Please read the full notice of this settlement (available here) carefully before filling out this Claim Form.

PART ONE: CLAIMANT INFORMATION

Provide your name and contact information below. It is your responsibility to notify the Settlement Administrator of any changes to your contact information after the submission of your Claim Form.

First Name

Last Name

Address 1

Address 2

City

State

Zip

Telephone Number

PART TWO: CLAIM INFORMATION

To qualify for a cash payment, you must have an Oregon address, and have purchased one of the Defendant’s allegedly mislabeled Select CBD Drops on or after June 19, 2021.

Please provide the approximate date you claim you purchased Select CBD Drops:

Date

Please provide the name of the location where your purchase was made:

Location Name

POTENTIAL CASH PAYMENT*:

You may be entitled to receive a cash payment of up to $200.00 if you purchased one of the Defendant’s allegedly mislabeled Select CBD Drops on or after June 19, 2021.

* The cash payments set out herein represent the maximum that you can receive under the settlement. The actual cash paid may be reduced depending on the aggregate total of claims submitted by all Settlement Class Members.

Please a payment method:

PART THREE: ATTESTATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United States of America that: (i) I purchased at least one of the Defendant’s allegedly mislabeled Select CBD Drops on or after June 19, 2021; (ii) I reside in Oregon; and (iii) all of the information on this Claim Form is true and correct to the best of my knowledge. I understand that my Claim Form may be subject to audit, verification, and Court review.

Signature

Date