Bayol, et al. v. Health-Ade LLC, et al.

In the United States District Court for the Northern District of California

Case No. 3:18-cv-01462 MMC

Settlement Claim Form

If you are a Class Member and wish to receive a payment, your completed Claim Form must be postmarked on or before August 27, 2019, or submitted online at www.hakombuchasettlement.com on or before August 27, 2019.

Please read the full notice of this settlement (available at www.hakombuchasettlement.com) carefully before filling out this Claim Form.

To be eligible to receive any benefits from the settlement obtained in this class action lawsuit, you must submit your claim form online or by mail:

ONLINE:        Visit www.hakombuchasettlement.com and submit your claim online.

MAIL:             Bayol v. Health-Ade LLC

                      RG/2 Claims Administration

                      P.O. Box 59479

                      Philadelphia, PA 19102-9479

PART ONE: CLAIMANT INFORMATION

PART TWO: PURCHASE INFORMATION

To qualify for a cash award, you must have purchased one or more of the following beverages (“Subject Products”) from March 6, 2014 through May 24, 2019:

  • Health-Ade kombucha tea, including but not limited to the following flavors: Beet; Blood Orange-Carrot-Ginger; California Grape; Cayenne Cleanse; Ginger-Lemon; Holiday Cheers; Jalapeño-Kiwi-Cucumber; Maca-Berry; Matcha+Cold Brew Coffee; The Original; Pink Lady Apple; Plum; Pomegranate; Power Greens; Reishi-Chocolate; Sweet Thorn.

TOTAL NUMBER OF SUBJECT PRODUCTS

Under the terms of the settlement, you are required to provide proof of purchase if you are claiming more than 10 units.  Please upload copies of supporting documents. If you are unable to provide proof of purchase, please reduce your claim to 10 units or less.



POTENTIAL CASH AWARD*: You may be entitled to receive a $4.00 cash award for every bottle of the Subject Products you purchased between March 6, 2014 and May 24, 2019, up to a maximum of $40.00 without Proof of Purchase.  You may receive a cash award of up to $80.00 based on the retail value of the Subject Products if you submit Proof of Purchase, such as receipts, establishing each purchase during the Class Period.  Packaging, including bar codes or UPCs, shall constitute Proof of Purchase only if the Subject Product(s) claimed to have been purchased can be identified from the packaging submitted.**

The cash will be sent in the form of a check.

* The cash awards set out herein represent the maximum that you can receive under the Settlement.  The actual cash awarded may be reduced depending on the aggregate total of claims submitted by all Class Members.
**Failure to include Proof of Purchase for cash claims in excess of $40.00 will result in the claim being reduced to $40.00 in cash.  Submission of false or fraudulent information may result in the claim being rejected in its entirety.

PART THREE: ATTESTATION UNDER PENALTY OF PERJURY

I declare under penalty of perjury under the laws of the United States of America that I purchased the products listed above between March 6, 2014 and May 24, 2019 and that all of the information on this Claim Form is true and correct to the best of my knowledge.  I understand that my Claim Form may be subject to audit, verification, and Court review.

 

SIGNING INSTRUCTIONS:

If not using a touchscreen device, click and drag your mouse to sign your name. 

Signed: *
clear
 +
Acknowledgement *

CLAIM FORM REMINDER CHECKLIST

Before submitting this Claim Form, please make sure you:

  1. Complete all fields in the Claimant Information section in Part One of this Claim Form.
  1. Provide the total number of bottles of the Subject Products you purchased between March 6, 2014 and May 24, 2019 in Part Two of this Claim Form.
  1. Indicate whether you are enclosing Proof of Purchase documentation.
  1. Sign the Attestation under penalty of perjury in Part Three of this Claim Form. You must sign the Attestation in order to be eligible to receive settlement benefits.

Please keep a copy of your Claim Form for your records.

QUESTIONS? VISIT www.hakombuchasettlement.com OR CALL 1-866-742-4955 TOLL-FREE