All Fields Must be Completed to Participate This is an Indirect Purchaser Settlement. By filling out this form you agree to donate your proceeds from the LCD Flat Panel Settlement to: Independent Arts & Media Complete this claim form to donate your refund from settlements totaling almost $1.1 billion. Your claim must be submitted online by December 6, 2012. You must answer the three eligibility questions below, by checking the boxes, to see if you are eligible.PART 1: ELIGIBILITY QUESTIONSDid you reside in one of the following states or the District of Columbia between January 1, 1999 and December 31, 2006: 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?*YesNoDid you buy a television, monitor and/or notebook computer containing an LCD Flat Panel within one of these states or the District of Columbia, for your own use and not for resale, while residing in that state or the District of Columbia between January 1, 1999 and December 31, 2006?*YesNoDid you buy a television, monitor and/or notebook computer containing an LCD Flat Panel from a company other than the following LCD Flat Panel manufacturers: AU Optronics, Chimei, Chunghwa, Epson, HannStar, Hitachi, LG, Samsung, Sharp or Toshiba? For example, if you purchased one of these products from a retailer like Best Buy or a computer manufacturer like Dell, your answer should be “Yes.” The brand of product does not change your answer. So, if you bought a Samsung-branded television or a Toshiba-branded notebook computer from Best Buy your answer is still “Yes.” However, for example, if your only purchase was a television or notebook computer bought directly from Samsung or Toshiba, your answer would be “No.”*YesNoYou are eligible for payment only if you answered “Yes” to all three Eligibility Questions above. You cannot file a claim if you answered “No” to any of the Eligibility Questions. PART 2: PURCHASE INFORMATIONEnter the total number of the following products you purchased from January 1, 1999 through December 31, 2006 which contain an LCD Flat Panel. Only include qualifying products for which you answered “Yes” to the three Eligibility Questions:Total Number of Televisions*Total Number of Monitors*Total Number of Notebooks*All claims are subject to audit and large claims will require verification.PART 3: CLASS MEMBER INFORMATIONSpecify one of the following:*IndividualBusiness (1-10 Employees)Business (11-50 Employees)Business (Greater than 50 Employees)Which branch of Independent Arts & Media would you like to donate to?*-- select a branch --Independent Arts & MediaCircus BellaCounterCorpLivable EnvironmentsMaximum RocknRollNewsdesk.orgShades: The Magazine for All Women of ColorPeoplePowerMediaNewsfunders.orgNichi Bei FoundationOhlone Profiles ProjectPawsense/Pride GamesPolitify.usSF Women's Film Festival/Women's Film InstituteShaping San FranciscoThe Bay BridgedRacing to ZeroVoiceboxYou, Me and the Fruit TreesExiled in AmericaJazzheimersVisions of HopeClub StrideDan Archer's ArchComixLast 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)*Businesses: Provide your Federal Taxpayer Identification NumberPART 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 LCD Class Action, including all powers necessary to submit the claim, receive and endorse payments to Independent Arts & Media, and any other necessary procedures to process, finalize, and forward the claim benefits to Independent Arts & Media. These powers will cease upon the completion claims process completion or actual notice received by DonateDirect of revocation of this power of agency. If you do not wish to donate your refund toward the non-profit mentioned above, go to https://lcdclass.com to file a claim for yourself.
