SETTLEMENT ADMINISTRATOR
C\O RUST CONSULTING INC - 5488
PO BOX 2563
FARIBAULT MN 55021-9563
F O R O F F I C I A L U S E O N LY
03
I MP O R TA N T L EG AL M ATERIAL S
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If the pre-printed information to the left is not correct
or if there is no pre-printed information, please check
the box and complete the information below:
Name:
Address:
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Zip Code:
OAKS v. SEARS, ROEBUCK & COMPANY
CLASS ACTION SETTLEMENT CLAIMS FORM
Complete and return to:
Class Action Administrator
c\o Rust Consulting, Inc. - 5488
PO Box 2563
Faribault, MN 55021-9563
This Claim Form is to be used by all purchasers and recipients, not for resale, of Kenmore brand gas grills with galvanized steel
fireboxes with model numbers 01566, 03495, 16142, 16154, 23673, 23676, 23681, 23682, 23683, 23766, 34172, 34176, 34178,
34308, and 34611, which were manufactured between October 2011 and September 2014 (the “Grills”). Individuals who already had
the firebox repair performed by Sears at no cost, as well as certain other categories of individuals, are NOT included in the Class.
This Claim Form is to be used to qualify for one of the following benefits, depending on which Type of Claimant you are:
Type 1: Class members who on the Effective Date possess a Grill which needs repair can receive either a free repair to the
firebox, a Sears gift card for $180.00, or a $125.00 cash payment.
Type 2: Class members who do not on the Effective Date possess their Grill and did not purchase a replacement can receive
either a Sears gift card for $180.00 or a $125.00 cash payment.
Type 3: Class members who on the Effective Date possess a Grill, Model # 23682, which cannot be repaired, can receive either
a Sears gift card for $180.00 or a $125.00 cash payment.
Type 4: Class members who on the Effective Date possess a Grill and already paid Sears to repair or replace the firebox of the
Grill can receive reimbursement of the amount paid to Sears to repair or replace the firebox on the Grill, including service charges.
Type 5: Class members who purchased a replacement because of rusting to the firebox prior to the Effective Date of the
Settlement can receive either a replacement firebox, or up to a $300.00 cash reimbursement for the price of the replacement
grill. (A Type 5 Claimant may receive reimbursement of the purchase price for the replacement grill up to the amount Sears
charged or quoted for repair of the Type 5 Claimant’s Grill, upon presentation of documentary proof that Sears charged or quoted
an amount over $300.00).
Type 6: Class members who purchased the Grill between January 1, 2011 and December 31, 2013, and who purchased a
replacement within 2½ years of the original purchase, but do not on the Effective Date possess their Grill and cannot provide any
photographic evidence of rusting or of a complaint to Sears about rusting, can receive a Sears gift card for $45.00.
To be eligible for a repair or other recovery, the Grill must exhibit Material Rusting of the firebox, but be otherwise functional and in
working order. As set forth hereinafter, a claimant must meet certain proof requirements to qualify for each type of recovery. Only the
original purchaser or recipient may receive recovery. Only one recovery is available for each affected Grill. Material Rusting means rust
impacting the structural integrity of the firebox tray, evidenced by a visible hole and/or break in the firebox caused by rust.
You must either file online at www.kenmorefireboxgrillsettlement.com or return your completed Claim Form and all required
documentation postmarked no later than January 26, 2018 to the Class Action Administrator at the address above to get a
replacement firebox, cash payment, or Sears gift card.
*5488*
*CFW*
*RUST*
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PART 1: TYPE OF CLAIM AND FORM OF RELIEF (REQUIRED FOR ALL CLAIMANTS)
1. Type of Claim:
Please check the Type of Claim that you are submitting, as described in the section above. You must select one Type of Claim
to be eligible for recovery.
Type 1
Type 2
Type 3
Type 4
Type 5
Type 6
2. Form of Relief:
Please check the Form of Relief that you are requesting for your Claim. The form of relief you choose must be available to the
Type of Claim identified in the preceding selection.
Free repair or replacement of firebox
$180 Sears gift card
$125 cash payment
Reimbursement of amount paid to Sears to repair or replace the firebox on the Grill
Amount: $
Reimbursement of purchase price for replacement grill
Amount: $
(not to exceed $300 without required documentation)
$45 Sears gift card
Notes concerning these elections: If a claimant submits evidence entitling that claimant to a certain Type of relief, but
mistakenly indicates another Type of relief, the Claims Administrator will process the Claim as if the proper Type was elected.
If a Claimant does not choose a form of relief, or chooses a form of relief not available for the Claim type at issue, the Claims
Administrator will provide the first-listed form of relief if the Claim is allowed.
PART 2: PROOF OF OWNERSHIP (REQUIRED FOR ALL CLAIMANTS)
1. Grill Information:
Model Number of your Kenmore grill:
2. Proof of Purchase:
To be eligible to receive certain of the settlement benefits, you must provide proof of ownership. This can be satisfied by
submitting a Sears receipt, or if a record of purchase of your grill is contained in Sears’ records. Sears’ records will be
reviewed for all claimants. Please check to indicate whether you are submitting a Sears receipt with this Claim Form, or
relying exclusively on Sears’ records.
I am submitting a Sears receipt showing purchase of the grill; OR
I will rely exclusively on Sears’ records for proof of purchase (upon selection of this option, Sears will review its records to
determine whether such proof exists; if the review does not identify sufficient proof of purchase, your Claim will be denied).
3. Original Recipient as a Gift:
I am the original recipient of the grill as a gift, not for resale.
PART 3: PROOF OF DAMAGE
1. Proof of Material Rusting:
To be eligible to receive any of the settlement benefits, you must provide at least one of the following forms of proof that your
grill experienced Material Rusting of the firebox. Claimant Types 1, 2, 3, 4, and 5 must submit one of the first two forms of
proof.) Please check the form of proof that you are providing with this Claim Form.
Photographic evidence of the Material Rusting of the firebox on the grill; AND/OR
Proof of prior complaints to Sears, in Sears’ records (for Type 2 and Type 5 Claimants only) showing complaint(s) of
rusting to firebox were communicated to Sears before the Effective Date (if Claimant relies solely on this option, Sears
will review its records to determine whether such proof exists; if the review does not identify sufficient proof of prior
complaints and you do not also submit photographic evidence, your Claim will be denied); AND/OR
Certification that the grill exhibited Material Rusting when you last possessed the grill (for Type 6 Claimant only).
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PART 4: CLAIM FOR REPAIR REIMBURSEMENT (REQUIRED FOR CLAIMANT TYPE 4)
Complete this section only if you are seeking reimbursement for qualifying out-of-pocket payments made to Sears before the
Effective Date for repair or replacement of your grill’s firebox.
1. Repair Details:
Purchase Date(s)
Repair Description(s)
$
Amount Paid for Parts and Labor for Repair or Replacement of Firebox
2. Proof of Repair Payment:
To be eligible to receive repair reimbursement, you must provide proof of repair payment. This can be satisfied by submitting
a Sears receipt or invoice, or if a record of repair of your grill is contained in Sears’ records. Sears’ records will be reviewed for
all claimants. Please check to indicate whether you are submitting a Sears receipt or invoice for repair with this Claim Form,
or relying exclusively on Sears’ records.
Receipt and/or invoice for repair payment to Sears showing that you paid the claimed amount for a repair or replacement
of your grill’s firebox; OR
I will rely exclusively on Sears’ records for proof of repair payment (upon selection of this option, Sears will review its
records to determine whether such proof exists; if the review does not identify sufficient proof of repair payment, your
Claim will be denied).
PART 5: CLAIM FOR REPLACEMENT REIMBURSEMENT (REQUIRED FOR CLAIMANT TYPE 5)
1. Replacement Details:
Brand of Grill Purchased
/
Purchase Date
/
$
Amount Paid for Replacement Grill
2. Proof of Replacement Grill Purchase:
To be eligible to receive reimbursement for your replacement grill, you must provide proof of purchase, before the Effective
Date, of the replacement grill. Please check the box below if you are providing proof.
Receipt for the replacement grill showing that you paid the claimed amount; OR
Proof that the purchase of your replacement grill is contained in Sears’ records (upon selection of this option, Sears will
review its records to determine whether such proof exists; if the review does not identify sufficient proof of purchase,
your Claim will be denied).
3. Documentation to Support Reimbursement Claim in Excess of $300.
To be eligible to receive reimbursement for your replacement grill in excess of $300, you must provide documentary
proof that Sears charged or quoted an amount over $300.00 for repair or replacement of the firebox for your Grill.
Please check this box if you are providing such proof.
PART 6: PROOF OF REPLACEMENT (REQUIRED FOR CLAIMANT TYPE 6)
1. Replacement Details:
Brand of Grill Purchased
/
Purchase Date
/
$
Amount Paid for Replacement Grill
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2. Proof of Replacement Grill Purchase:
To be eligible for this relief you must provide proof of purchase of a replacement grill within 30 months of the purchase of
your original Grill. Please check the box below if you are providing proof.
Receipt for the replacement grill showing that you paid the claimed amount; OR
Proof that the purchase of your replacement grill is contained in Sears’ records (upon selection of this option, Sears will
review its records to determine whether such proof exists; if the review does not identify sufficient proof of purchase,
your Claim will be denied).
PART 7: INSTRUCTIONS, CONFIRMATION, AND SIGNATURE
1. Submission of Supporting Documents:
PLEASE SUBMIT ANY AND ALL DOCUMENTS SUPPORTING YOUR CLAIM WITH THIS CLAIM FORM, INCLUDING BUT NOT
LIMITED TO PHOTOGRAPHS, RECEIPTS, INVOICES, CREDIT CARD STATEMENTS, PROOF OF PAYMENT.
2. Sworn Confirmation:
Please confirm the following statement under penalty of perjury. All claimants must complete and sign this section, regardless
of the Type of claim submitted or the form of proof of purchase provided.
SWORN CONFIRMATION: I swear, under penalty of perjury under the laws of the United States of America, that the following
statements are true and correct:
(1) I am the original purchaser or recipient, not for resale, of the grill claimed on this form; AND
(2) (a) (for Claim Types 1, 3, and 4) I currently possess the grill on this form, the firebox exhibits or exhibited Material
Rusting, and the grill is otherwise functional and in working order; OR
(b) (for Claim Type 2) I no longer possess the grill on this form, but the firebox exhibited Material Rusting and the grill was
otherwise functional and in working order when I last possessed it; OR
(c) (for Claim Type 5) The grill on this form exhibited Material Rusting and I paid for a replacement;
(d) (for Claim Type 6) The firebox exhibited Material Rusting but was otherwise functional when I last possessed it;
AND
(3) I have not previously received any refund or reimbursement for any claimed expenses stated above; AND
(4) I qualify for relief under the Type of claim indicated above; and
(5) All of the information provided in this form or submitted with this form is true and accurate. Any photos submitted
herewith accurately show the condition of my Kenmore grill.
Signature
Date
Name:
Contact Information:
Address:
City:
State:
Zip:
Email:
Telephone: (
)
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