All Fields Must be Completed to Participate Complete this claim form to donate your refund from settlements totaling almost $576.75 million. Your claim must be submitted by December 7, 2015. *UPDATE: Even though the claim filing deadline has passed, because claims are still being accepted online, we feel hopeful that claims filed in the coming weeks will still be accepted for payment. You must answer “Yes" to at least 2 eligibility questions below, by checking the boxes, to see if you are eligible. Important Eligibility Note: Sony© branded televisions and monitors are NOT eligible to be included in this case. All other brands of CRT televisions and monitors are eligible.PART 1: ELIGIBILITY QUESTIONSDid you purchase a CRT Product for your own use and not for resale in the following states between March 1, 1995, and November 25, 2007: Arizona, California, Florida, Iowa, Kansas, Maine, Michigan, Minnesota, Mississippi, New Mexico, New York, North Carolina, North Dakota, South Dakota, Tennessee, Vermont, West Virginia, Wisconsin or the District of Columbia?YesNoHawaii between June 25, 2002, and November 25, 2007?YesNoNebraska between July 20, 2002, and November 25, 2007?YesNoNevada between February 4,1999, and November 25, 2007?YesNoDid you purchase a CRT Product from a retail store or someone other than the manufacturer of the CRT Product? For example, if you purchased a CRT television or computer monitor from a retailer like Best Buy or a computer manufacturer like Dell, then your answer should be “Yes.” If you made no purchases from a retailer or other supplier and you only purchased a CRT television or computer monitor directly from a manufacturer of CRT Products, then your answer should be “No.”*YesNoYou are eligible for payment only if you answered “Yes” for at least one state listed in Question 1 subparts (a), (b), (c) or (d), AND Question 2. PART 2: PURCHASE INFORMATIONIn order to make a valid claim, you must have purchased your CRT Product(s) in an eligible state during the specified time frames (“ClaimsPeriods”). The Claims Period for the eligible states is between March 1, 1995, and November 25, 2007, except for purchases in Hawaii, Nebraska, and Nevada which have slightly shorter Claims Periods. Purchases in Hawaii must have been made between June 25, 2002, and November 25, 2007 Purchases in Nebraska must have been made between July 20, 2002, and November 25, 2007 Purchases in Nevada must have been made between February 4,1999, and November 25, 2007 Enter the total number of CRT Products you purchased between March 1, 1995, and November 25, 2007 (see modified class period dates above for purchases made in Hawaii, Nebraska, or Nevada). Only include qualifying products for which you answered “Yes” to the Eligibility Questions in Part 1:Standard CRT Television (screen size less than 30 inches):*Large CRT Television (screen size 30 inches or larger):*CRT Computer Monitor*Other CRT Product(s)(please specify):Important Notes: *All claims are subject to audit and large claims will require verification **Sony® branded televisions and monitors are NOT eligible to be included in this case ***All claimants should keep any proof of purchasePART 3: CLASS MEMBERSpecify one of the following:*IndividualBusiness (1-10 Employees)Business (11-50 Employees)Business (Greater than 50 Employees)Last Name*First Name*Entity Name (Business Use Only)Person to contact if there are questions regarding this claimNumber and Street or P.O. Box*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip*Telephone Number (Day)--Email* Individuals: Provide the last 4 digits of your Social Security Number (only to avoid duplicate claims)or Provide Date of Birth(Month and Year):Businesses: Provide your Federal Taxpayer Identification Numberor Provide Date of Formation or Incorporation:PART 4: SIGN AND DATE CLAIM FORMI (we) declare under penalty of perjury under the laws of the United States of America, that the information provided in this Claim Form is true and correct. E-Signature* Date*Print Name*Title (if you are filling out this form for a business)Claims may be audited and any false or fraudulent claim is subject to prosecution.I appoint DonateDirect to act as my representative in the filing, processing, and collection of my claim in the CRT Class Action, including all powers necessary to submit the claim, receive and endorse payments to NIMBY, and any other necessary procedures to process, finalize, and forward the claim benefits to NIMBY. These powers will cease upon the completion claims process completion or actual notice received by DonateDirect of revocation of this power of agency. Return your completed claim form to your DonateDirect program representativeIf you do not wish to donate your refund to the non-profit mentioned above, go to https://www.crtclaims.com to file a claim for yourself.
