Nivea Cellulite Cream Claim Form (With Proof of Purchase)
CLAIM FORM – NIVEA GOOD-BYE CELLULITE PRODUCTS AND MY SILHOUETTE!
SETTLEMENT
(WITH PROOF OF PURCHASE)
Please fill out the information below completely and legibly. If the information you provide is incomplete, illegible, or inaccurate, your claim may be rejected in whole or in part. A check will be sent to the person whose name appears on the claim form.
Name
Address
| City | State | Zip |
( )
Telephone Number
1. Complete the chart below with all of the requested information.
| Date of Purchase (Identify only purchases between January 1, 2007 and April 1, 2012) |
Location of Purchase (Identify the name of the retailer and state where product was purchased) |
Product Purchased (NIVEA Good-Bye Cellulite Gel Cream, NIVEA Good-Bye Cellulite Gel Patches, NIVEA Good-Bye Cellulite 30-Day Body Beauty Program, NIVEA Good-Bye Cellulite Fast Acting Serum, NIVEA My Silhouette! Redefining Gel Cream) |
Price Paid |
PROOF OF PURCHASE: YOU MUST INCLUDE ADEQUATE PROOF OF PURCHASE WITH THIS CLAIM FORM. “Adequate Proof of Purchase” means cash register receipts or similar documentation that identifies the product purchased, its retail price, and date of purchase.
2. Please answer the following questions, which apply only to purchases of NIVEA Good-Bye Cellulite products and not to purchases of NIVEA My Silhouette! Redefining Gel Cream products:
A. I purchased one or more Good-Bye Cellulite products in California or Florida on or before February 15, 2011.
Yes
No
B. I previously submitted a claim for the purchase of one or more Good-Bye Cellulite products in the settlement of cases captioned Phillips v. Beiersdorf North America, Inc. and Beiersdorf, Inc., No. 3:09-cv-1891-CFD (D. Conn.) and Wiener v. Beiersdorf North America, Inc. and Beiersdorf, Inc., No. 3:10-cv-159-CFD (D. Conn.).
Yes
No
C. If your answer to 2.A or 2.B is “Yes,” please circle, on the chart above, which of your purchases were made before February 15, 2011 and/or for which purchases you submitted a claim. You are not entitled to a recovery under this settlement for those products that you circle.
I DECLARE UNDER PENALTY OF PERJURY THAT I PURCHASED THE PRODUCTS LISTED ABOVE AND THAT ALL OF THE INFORMATION I HAVE PROVIDED IN THIS DOCUMENT OR SUBMITTED IN CONNECTION WITH THIS CLAIM IS TRUE AND CORRECT.
Signature: _________________________ Executed on:__________________ [INSERT DATE]
Mail this Claim Form, along with your Proof of Purchase, to the following address:
GBC MS Settlement Administrator
c/o Strategic Claims Services
600 N Jackson Street – Suite 3
Media, PA 19063.
YOUR CLAIM FORM MUST BE POSTMARKED ON OR BEFORE MAY 31, 2012.
