FLEXIBLE POLYURETHANE FOAM SETTLEMENTS INSTRUCTIONS The deadline to file a Claim is February 29, 2016. We need your paperwork back as soon as possible so we can review, double check and complete all your forms, and prepare supporting documents. Please do the following now. Step 1: PRINT, COMPLETE, SIGN AND DATE ALL THE FORMS. PLEASE PRINT CLEARLY. QUESTIONNAIRE: Please fill out and sign the Questionnaire. This gives us key information to prepare your Claim. RETAINER AGREEMENT: Please fill out and sign. (This form hires us to help you with your claim.) REPRESENTATION LETTER: Please fill out, and sign in blue or black ink. This lets the court appointed claims processing company work with us on your claim and issue your payment check. CLAIM FORM: Please fill out and sign in blue or black ink. Step 2: RETURN EVERYTHING TO US AT ONCE After completing and signing the Questionnaire, Retainer Agreement and Representation Letter, send the originals to us as soon as possible. Send everything together by mail, FedEx, UPS, or other means. Keep copies of everything for your records. Do not send anything to the claims processing company. Because we represent you, it needs the documents to come from us, together with supporting documents we prepare. Sending anything to them separately will cause delay and confusion and risk your claim not being paid. Send all documents only to us. Step 3: RELAX AND LET US DO THE REST FOR YOU When we receive your papers, we will double check everything, then prepare your Claim \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\instructions Dec 29 2015.wpd January 14, 2016 (9:50am) Page 1 of 2
Form for your signature. Meanwhile we will prepare other supporting materials. We may contact you to make sure you are claiming as much money as possible. We will then file your Claim Form along with other documentation. After filing your Claim, we stay in touch with the claims processing company as needed. We deal with any questions or requests they may have. We also stay in touch with you and let you know what s happening with your claim. When your claim is paid, we review the amount to make sure you ve received every dollar you re due. If the claims processing company has questions, it will contact us rather than you, and we will deal with it. We will ask you for additional information only if absolutely necessary. Otherwise we will take care of everything. Updated information will be available on our website www.polyfoamrefund.com Class Action Claims Center 2272 Colorado Boulevard, Suite 1500 Los Angeles, California 90041 Tel: (213) 625 0064 Fax: (213) 625 0079 Email: CACC955@Yahoo.com www.polyfoamrefund.com \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\instructions Dec 29 2015.wpd January 14, 2016 (9:50am) Page 2 of 2
Class Action Claims Center 2272 Colorado Boulevard, Suite 1500 Los Angeles, California 90041 Tel: (213) 625 0064 Fax: (213) 625 0079 CACC955@Yahoo.com www.polyfoamrefund.com QUESTIONNAIRE Flexible Polyurethane Foam Settlements SECTION 1: YOUR BUSINESS INFORMATION Your name: Your job title: Person to contact about this claim: Their job title: Business/ entity name: Street, City, State, Zip: Tel:( ) Ext: Fax:( ) Email: Business is: Sole Proprietorship Corp. LLC Partnership Other Number of employees Business type (e.g., realtor, motel, farm) If you are a hotel or motel: How many rooms? Federal taxpayer identification number: G Sole Proprietorship: Give SSN #: GGG-GG-GGGG G Corp., LLC, etc.: Give EIN #: GG-GGGGGGG How did you hear about this opportunity? G Phone call G Email G Letter G Trade Organization G News article G Word of Mouth G Other \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\questionnaire Dec 29 2015.wpd January 14, 2016 (9:51am) Page 1 of 3
SECTION 2: ARE YOU ELIGIBLE? Did you buy, not for resale:! any upholstered furniture (for example, a sofa with foam cushions), or carpet underlay (also known as carpet padding or carpet cushion), or bedding product (for example, mattresses, mattress toppers, or pillows) containing flexible polyurethane foam; AND! which was made in the United States ; AND! which you bought between January 1, 1999 and August 1, 2015; AND! which you bought in any of the following states: Alabama, Arizona, California, Colorado, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Dakota, Tennessee, Vermont, West Virginia, Wisconsin, or the District of Columbia? G Yes G No You are eligible for payment only if you answered Yes to the Eligibility Question above. \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\questionnaire Dec 29 2015.wpd January 14, 2016 (9:51am) Page 2 of 3
SECTION 3: PURCHASE INFORMATION Enter below the total dollar amount paid for all products within each category that you purchased in any of the States listed in Section 2 (the Eligibility Question) during the time period January 1, 1999 to August 1, 2015 which contained U.S.-made flexible polyurethane foam. Only include products for which you answered Yes to the Eligibility Question (in Section 2, above). If you don t know the exact purchase amounts, give your best estimates. If you bought items in more than one state, make extra copies of this page and fill one out for each state. What State did you buy the products below in: Total Amount ($) of Carpet Underlay containing polyurethane foam: Total Amount ($) of Bedding Products (for example, pillows, mattresses, or mattress toppers) containing polyurethane foam: $,,. oo $,,. oo Total Amount ($) of Upholstered Furniture $,,. oo (for example, sofas or chairs) containing polyurethane foam: SECTION 4: SIGNATURE X Date: (Signature) Print Name: Job Title Reminder: Complete everything. If not sure of something, give your best information or estimate. Class Action Claims Center 2272 Colorado Boulevard, Suite 1500 Los Angeles, California 90041 Tel: (213) 625 0064 Fax: (213) 625 0079 CACC955@Yahoo.com www.polyfoamrefund.com \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\questionnaire Dec 29 2015.wpd January 14, 2016 (9:51am) Page 3 of 3
Class Action Claims Center 2272 Colorado Boulevard, Suite 1500 Los Angeles, California 90041 Tel: (213) 625 0064 Fax: (213) 625 0079 CACC955@Yahoo.com www.polyfoamrefund.com Retainer Agreement FLEXIBLE POLYURETHANE FOAM SETTLEMENTS I hereby hire your firm, Class Action Claims Center ( Center ) as my sole representative and agent, to help prepare and file a Claim for me to be paid money in the above litigation, and represent me in seeking that money. In return for Center s services, any money obtained will be split equally. Center will use its best efforts, but can not guarantee or promise results. I authorize Center (including its agents, employees, nominees, assignees and attorneys) to deal with the claims administrator, attorneys, court and others, to discuss my claim with them, to give and receive information and documents, to endorse my name to and deposit any settlement check, to pay me by check, and to try to recover as much money as possible for me. I understand that Center is a private firm, not the lawyer for the class, a government agency, court representative, or the court-appointed claims processing company. Using Center s services is my choice. I have not been sued and Center is not suing anyone for me. Center has not offered and will not offer legal, tax or business advice on this matter. If this is a business, I have authority to make this agreement. A photocopy or digital copy of this document is as valid as the original. I understand that only one claim per class member is permitted. X Date (Signature) My Name: (Print): Business Name: My Job Title: Form of business: G Sole Proprietor G Corporation G LLC G Partnership G Other: \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\retainer Agreement Dec 29 2015.wpd January 14, 2016 (9:53am) Pg 1 of 1
REPRESENTATION LETTER Flexible Polyurethane Foam Settlements Dear Claims Administrator: Class Action Claims Center 2272 Colorado Boulevard, Suite 1500 Los Angeles, California 90041 Tel: (213) 625 0064 Fax: (213) 625 0079 Email: CACC955@Yahoo.com www.polyfoamrefund.com This business (or I) has submitted a claim in the above litigation. Class Action Claims Center ( Center ) represents this business (or me) in this claim. If this is a claim by a business, I have authority to act and sign for it, and I am doing so. The words I or me used below mean the business as well as me. I authorize Center to deal with the claims administrator, attorneys, court and any others in this matter. You are free to provide information and documents to it, to receive information and documents from it, and to discuss this claim with it. Center and those acting on its behalf, such as its employees, agents and attorneys, has my full authority to pursue, settle, compromise, withdraw, or appeal denial or partial denial of, this claim and to act as it deems necessary or appropriate. For all matters involving this claim, please deal with Center. If this claim is approved, please make payment payable to the claimant this business or me and mail it to Center at Center s address. I understand that Center is not the attorney or agent of the named representative plaintiffs, the class or the defendants. Center is also not a government agency, court, court representative or agent, or the court-appointed claims administration company. I may file a claim on my own; using Center s services is my choice. A photocopy or digital copy of this document is as valid as the original. I know only one claim per person or business is permitted, and this is the only one. X Date (Signature) Print your name: Claimant is: [ ] A person [ ] A business If business is making the claim: Print name of business: Print your job title: Class Action Claims Center \\Dla-svr_0715\t-docs\1-Js-Docs\1-POLY FOAM website\representation Letter businesses Dec 29 2015.wpd Jan 14, 2016 9:54 am Pg 1 of 1
MUST BE POSTMARKED BY FEBRUARY 29, 2016 In re Polyurethane Foam Antitrust Litigation c/o A.B. Data, Ltd. P.O. Box 170500 Milwaukee, WI 53217 Toll-Free: 1-866-302-7323 www.polyfoamclassaction.com FOR OFFICIAL USE ONLY CONSUMER PROOF OF CLAIM AND RELEASE Complete this Claim Form to receive a payment from one or more of the following nine Settlements with a total value of $151,250,000. YOUR CLAIM WILL BE CONSIDERED FOR ALL NINE OF THE FOLLOWING SETTLEMENTS UNLESS YOU CHECK ONE OR MORE OF THE BOXES BELOW. I do not wish to participate in the following Settlement(s): the Settlement with Carpenter Co. ($63,500,000); the Settlement with FFP Holdings LLC ($2,750,000); the Settlement with Future Foam, Inc. ($10,500,000); the Settlement with FXI Holdings, Inc. ($9,000,000, plus costs solely for Notice and Notice Administration of up to $500,000); the Settlement with Hickory Springs Manufacturing Company. ($10,250,000); the Settlement with Leggett & Platt Incorporated. ($26,500,000); the Settlement with Mohawk Industries, Inc. ($16,000,000); the Settlement with Vitafoam Products Canada Limited and Vitafoam, Inc. ($2,750,000); the Settlement with Woodbridge Foam Corporation, Woodbridge Sales & Engineering, Inc., and Woodbridge Foam Fabricating, Inc. ($9,500,000) Your claim must be submitted online or postmarked by February 29, 2016. Consumers (individual or business) can request a payment from the above Settlements if you meet the eligibility requirements listed below. You must answer the Eligibility Question below by checking the box, to see if you are eligible. Section 1: Eligibility Question Did you buy, not for resale: any upholstered furniture (for example, a sofa with foam cushions), or carpet underlay (also known as carpet padding or carpet cushion), or bedding product (for example, mattresses, mattress toppers, or pillows) containing flexible polyurethane foam; which was manufactured in the United States; and which you purchased during the time period January 1, 1999 to August 1, 2015; and which you purchased in one of the following states: Alabama, Arizona, California, Colorado, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, Rhode Island, South Dakota, Tennessee, Vermont, West Virginia, Wisconsin, or the District of Columbia? Yes No You are eligible for payment only if you answered Yes to the Eligibility Question above. Page 1 of 3
Section 2: Class Member Information Last Name First Name Business Entity Name Person to contact if there are questions regarding this claim: CLASS ACTION CLAIMS CENTER Specify one of the following: Individual Business Business Business (1-10 Employees) (11-50 Employees) (Greater than 50 Employees) Street Address 2272 COLORADO BLVD., SUITE 1500 City State Zip Code LOS ANGELES CA 90041 Daytime Telephone Number Section 3: Purchase Information Email Address (213) 625-0064 CACC955@YAHOO.COM Enter below the total dollar amount paid for all products within each category that you purchased in any of the States listed in Section 1 (the Eligibility Question) during the time period January 1, 1999 to August 1, 2015 which contained U.S.-made flexible polyurethane foam. If you are claiming purchases made in multiple States, make copies of this page for each State and only include purchases for one State per page. Only include products for which you answered Yes to the Eligibility Question above: Identify the State where purchases claimed below were made: Total Amount ($) of Carpet Underlay containing polyurethane foam: Total Amount ($) of Bedding Products (for example, pillows, mattresses, or mattress toppers) containing polyurethane foam: Total Amount ($) of Upholstered Furniture (for example, sofas or chairs) containing polyurethane foam:,,.00,,.00,,.00 All information submitted in a Proof of Claim is subject to further inquiry and verification. The Claims Administrator may ask you to provide supporting information or documentation. Failure to provide such requested information or documentation might adversely affect, or result in denial of, your claim. All claims totaling more than $100,000 must provide documentation supporting the total amount of purchases for which you are submitting a claim. Documentation should include the product name, date of purchase, State, and net purchase amount, and be kept in the normal course of business. Receipts, electronic summaries, or similar records are preferred. Any supporting documentation should be submitted as legible copies do not send originals, but maintain them in your records for additional verification or clarification, if needed. Page 2 of 3
Section 4: Certification and Substitute W-9 Enter the Claimant s federal taxpayer identification number: - - OR - Social Security Number Employer Identification Number By signing and submitting this Proof of Claim form, the Claimant, or the person acting on behalf of the Claimant, certifies that: 1. The information provided in this Claim Form is accurate and complete to the best of my knowledge, information, and belief; and 2. I am authorized to submit this Claim Form on behalf of the Claimant; and 3. The Claimant is a member of the Settlement Classes and did not request to be excluded from the Indirect Purchaser Settlement Class; and 4. The Claimant is neither a Defendant, nor a parent, employee, subsidiary, affiliate, or co-conspirator of a Defendant; and 5. The Claimant is not filing this Claim Form on behalf of a governmental entity; and 6. The Claimant submits to the jurisdiction of the United States District Court for the Northern District of Ohio with respect to this claim as a Settlement Class Member and for purposes of enforcing the releases below, in the Notice, and in the Settlement Agreement; and 7. The Claimant hereby warrants and represents that the Claimant has not assigned or transferred or purported to assign or transfer, voluntarily or involuntarily, any matter released pursuant to this release or any other part or portion thereof; and 8. The Social Security number or Taxpayer Identification Number shown on this form is correct and the Claimant is a U.S. resident Taxpayer; and 9. The Claimant is NOT subject to backup withholding under the provisions of Section 3406 (a)(1)(c) of the Internal Revenue Code because: (a) the Claimant is exempt from backup withholding; or (b) the Claimant has not been notified by the Internal Revenue Service that the Claimant is subject to backup withholding as a result of a failure to report all interest or dividends; or (c) the Internal Revenue Service has notified the Claimant that the Claimant is no longer subject to backup withholding; and (NOTE: If the Claimant has been notified by the Internal Revenue Service that the Claimant is subject to backup withholding, you must cross out this Item.) 10. The Claimant has not submitted any other claim covering the same purchases, and has not authorized any person or entity to do so on the Claimant s behalf; and 11. The Claimant agrees to furnish additional information regarding this Proof of Claim that the Claims Administrator, Lead Counsel, or the Court may require. UNDER THE PENALTIES OF PERJURY, I CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME ON THIS PROOF OF CLAIM FORM IS TRUE, CORRECT, AND COMPLETE, AND THAT THE DOCUMENTS SUBMITTED HEREWITH ARE TRUE AND CORRECT COPIES OF WHAT THEY PURPORT TO BE. I HAVE READ AND AGREE TO THE TERMS OF: (1) THE RELEASES LISTED IN SECTION 5 OF THE CLAIM FORM, AND (2) THE LONG FORM LEGAL NOTICE OF FLEXIBLE POLYURETHANE FOAM SETTLEMENTS. Please note that signing a Claim Form that contains false information could constitute perjury. Signature Print Name / / Date Title (if you are filing out this form for a business) Page 3 of 3