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Quixtar Class

CLAIM FORM

Enter Your Information (All fields marked with an * are required)

Claim Forms must be postmarked or submitted online no later than March 15, 2013.

If you received an email or postcard notice, a "Claimant ID Number" is located on the email or postcard you received. Please enter and confirm that information below. If you did not receive an email or postcard or do not have the Claimant ID Number, please proceed to Section I.

Claimant ID Number:    
Confirm Claimant ID Number:

SECTION I: INSTRUCTIONS

If you were a Quixtar Independent Business Owner ("IBO") after January 1, 2003, but you resigned as an IBO by February 21, 2012, you may be eligible to receive:

  • A bundle of free Quixtar products (currently estimated to have a $150 retail value, although the value may be greater or lesser depending on the number of new claims filed) (see SECTION II: PRODUCT CREDIT).
  • A partial refund (currently estimated at 20%, may be more or less depending on number of new claims filed) (maximum $2,000) of your expenditures on business support materials (see SECTION III: CASH REFUND FOR BSM EXPENDITURES).
  • No new hardship claims may be filed at this time. Hardship claims previously filed will be determined by the Special Master appointed by the Court. If you filed a hardship claim and you receive a letter from the Claims Administrator requesting additional documentation of you claim, you must provide the requested documentation or your claim will be denied.

To determine your eligibility for these benefits, complete the applicable section(s) of this Claim Form no later than March 15, 2013.

It is important that all of the information you provide in this Claim Form is true, accurate, and complete. Persons who submit false or fraudulent claims will not be eligible for compensation.

NOTE: If you were not a Quixtar Independent Business Owner ("IBO") during the period outlined above, or if you are currently a Quixtar IBO, you are not entitled to compensation under the Settlement Agreement.

*First Name:
Middle Initial:
*Last Name:
*Address Line One:
Address Line Two:
*City:
*State:
*Zip:
Phone Number
xxx-xxx-xxxx:
*Email address:
IBO Number (if available):

SECTION II: PRODUCT CREDIT

Complete this Section if you paid an initial registration fee to become a Quixtar IBO.

By checking here, I certify that I paid an initial registration fee to become a Quixtar IBO. Please rank the following twelve product bundles in order of preference (detailed information about each product is available HERE):
Family Supplements 1= First
 
Supplements and skin care 2 = Second
 
Supplements and skin care (oily skin) 3 = Third
 
Double X supplement 4 = Fourth
 
Artistry and Nutrilite - Women 5 = Fifth
 
Tolsom and Nutrilite - Men 6 = Sixth
 
Laundry care and Immune supplements 7 = Seventh
 
Laundry care and Him & Hers supplements 8 = Eighth
 
Weight Management 9 = Ninth
 
Personal Care 10 = Tenth
 
Energy 11 = Eleventh
 
Sports 12 = Twelth
 

SECTION III: CASH REFUND FOR BSM EXPENDITURES

Complete this Section ONLY if you have receipts, credit card statements, or other forms of proof (your own signed statement may be acceptable) that you spent at least $100 more on business support materials (books, tapes, and function tickets) than you received from re-selling business support materials.

By checking here, I certify that the amount I spent on business support materials is at least $100 more than I received from re-selling business support materials. On request, I will submit a signed statement attesting to my expenditures on business support materials. (Note: For your statements you may use the form HERE.)

How much do you estimate spending on Business Support Materials during the January 1, 2003 - February 21, 2012 Class Period?
   
How much money, if any, did you receive from re-selling business support materials?
   
Did you receive a profit from operating your Quixtar business?

SECTION IV: SIGN

I swear that I was a Quixtar Independent Business Owner at some time after January 1, 2003; that I am not a current Quixtar Independent Business Owner; that I quit my involvement with Quixtar on or before February 21, 2012; and that all information provided in this Claim Form, including any information provided in enclosed documents, is true, accurate, and complete to the best of my knowledge. By signing this Claim Form, I acknowledge that the Claims Administrator may ask Quixtar to provide certain information related to my Quixtar-related business (including tax forms and other financial data) to verify my Claim.

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