Moore, et al. v. Angie’s List, Inc. Claim Form
Must Be Submitted By: November 15, 2016
CLAIMANT INFORMATION
FIRST NAME:
MI:
LAST NAME:
E-MAIL ADDRESS USED FOR YOUR ANGIE’S LIST ACCOUNT OR:
(This will be used to verify your claim.)
YOUR MEMBER ID:
E-MAIL ADDRESS FOR FUTURE SETTLEMENT COMMUNICATIONS:
(Enter if different from Angie’s List account e-mail address.)
SELECTED RELIEF
Please complete this Claim Form to submit a Claim. First, select the period or periods for which you paid to
purchase or renew an Angie’s List Membership. Second, for each such period selected, choose whether you want
to receive a cash payment or membership benefit. You may select only a single benefit (i.e., cash payment or
period of membership). Finally, complete the certification below.
Group A Eligibility
Period
Cash Payment
Period of Membership
Purchased or
Estimated Cash
renewed membership
Payment of $10.00.*
during Group A Period
(March 11, 2009
through December 31,
2013)
Group B Eligibility
Cash Payment
Period
One Month of Membership for Each Full Year of Paid
Membership During Group A Period, Up to a Maximum of Four
(4) Months of Membership at Your Most Recent Level of Paying
Membership as of July 12, 2016.
Purchased or
Estimated Cash
renewed membership
Payment of $5.00.*
during Group B Period
(January 1, 2014
through July 12, 2016)
One Month of Membership for Each Full Year of Paid
Membership During Group B Period, Up to a Maximum of Two
(2) Months at Your Most Recent Level of Paying Membership as
of July 12, 2016.
Period of Membership
* Those selecting a cash payment option must supply a valid mailing address below. Note that the actual cash
payment will be subject to a pro rata adjustment upwards or downwards depending on the number of eligible
Settlement Class Members who select the cash option.
Street:
Apt/Suite:
City:
State:
Telephone Number:
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01-CA9115
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ZIP Code:
CERTIFICATION
1. I certify that I am a member of the Settlement Class, and have not requested exclusion from the settlement.
2. I certify that I was not aware at the time I purchased my Angie’s List membership that service providers could
pay Angie’s List to advertise, to offer promotions and/or coupons, or to secure benefits from Angie’s List.
3. I understand my Claim is subject to review by the Settlement Administrator, and I may be contacted if there are
questions about my Claim or if additional information is needed to verify my Claim. I also understand that my
Claim will be denied if the information I have submitted is incomplete, false, or inaccurate.
4. I certify that the foregoing information supplied by the undersigned is true and correct to the best of my knowledge.
Signature**:
Date of Certification:
–
MM
–
DD
YYYY
**If the Claimant is not an individual, or if the Claimant is not the person completing the Certification, please also
provide the capacity of the person signing (e.g., Legal Representative, Executor, President, Trustee):
Authority of Signator:
Reminder Checklist:
1. Please electronically sign this Claim Form.
2. Keep a copy of your completed Claim Form for your records.
3. If you move or your name changes, please send your new information to Epiq Systems, Inc. via the Settlement
Website.
REMINDER: SUBMIT OR POSTMARK THIS CLAIM FORM ON OR BEFORE NOVEMBER 15, 2016,
OR YOUR CLAIM WILL BE REJECTED.
If you have any questions about this Claim Form, visit www.MoorevALsettlement.com or call the Moore v. Angie’s
List Settlement Administrator at 1-888-293-9919.
02-CA9115
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