Submit Claim | Michael Hester v. Walmart Settlement

CLAIM FORM & VERIFICATION

QUALIFICATIONS & INSTRUCTIONS:

If you purchased an Onn brand power bank (a portable charger), you may be eligible to participate in this Settlement.

Under the Settlement, eligible Settlement Class Members may receive a share of the Settlement proceeds in the form of a payment by mailed check, ACH, or PayPal. The ACH and PayPal options are only available for Claims filed online. Additional information regarding how to submit a Claim, the value of a Claim, and about the Settlement itself is provided in the Notice of Class Settlement and in the Settlement Agreement.

To participate in the Settlement and to submit a Claim, you must be an eligible Settlement Class Member and complete and postmark a paper Claim Form or submit a claim online on or before 11:59 p.m. [PST] on November 19, 2020. All of the questions and information must be fully and accurately completed. Any Settlement Class Member Payment will be sent to the mailing address provided below. Failure to provide complete and accurate information could result in the denial of your Claim.

SECTION A: CLAIMANT INFORMATION

Provide your name and contact information below. It is your responsibility to notify the Claims Administrator of any changes to your contact information after the submission of your Proof of Claim and Verification Form.

First Name *

M.I.

Last Name *

Current Mailing Address *

Unit/Apt.

City *

State *

Zip Code *

Telephone Number

Email Address *

* Required Fields

SECTION B: WALMART PURCHASE INFORMATION

1. Did you purchase any Onn brand power bank?

Yes

If you answered “Yes” to the preceding question, please answer the following:

2. Identify the Walmart location(s), including retail store or Walmart.com, where you made a purchase of an Onn brand power bank.

Walmart.com

Retail Store

2a. If you selected Retail Store above, provide the location(s) of your purchase:

City	State

+ Add Location

3. Identify the year you purchased the Onn brand power bank(s) claimed above. If you purchased an Onn brand power bank on more than one occasion, please enter each purchase separately, even if they are in the same year, and describe each occasion.

Year	Description

+ Add Occasion

4. Enter the number of Onn power banks you purchased in the box next to the applicable model(s) below. If you are claiming more than 5 purchases, you must submit adequate proof of purchase.*

Number Purchased

1400 mAh Power Bank

1800 mAh Power Bank

2000 mAh Power Bank

2200 mAh Power Bank

Number Purchased

3350 mAh Power Bank

4000 mAh Power Bank

4400 mAh Power Bank

6700 mAh Power Bank

*Examples of adequate proof of purchase are receipts, warranty claims, or pictures of the product. Insufficient proof will result in a reduction of allowable claimed power banks to the maximum allowable without proof of purchase.

5. Identify your preferred method of payment if you are determined to be an eligible Settlement Class Member who filed a complete and accurate Claim Form:

Mailed Check

Paypal

ACH (electronic bank transfer)

SECTION C: PROOF OF PURCHASE

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

Select File for Upload:

File Description:

File List: No Files Selected

SECTION D: ACKNOWLEDGEMENT

I affirm, under penalty of perjury, that the information I have provided on this Claim Form is true and correct to the best of my knowledge, and that this is the only Claim Form that I have submitted. I further understand, acknowledge, and agree that I am eligible to receive only ONE payment from this Settlement based on my eligibility as a Settlement Class Member. I further understand, acknowledge, and agree that the amount I will receive shall be calculated in accordance with the terms of the Settlement Agreement, and will be subject to the terms of the Settlement Agreement, including the Release of Claims as more fully described in the Settlement Agreement.

Type your name to electronically sign your Claim Form.

Date

Michael Hester v. Walmart, Inc.

Case No. 5:18-cv-05225-TLB

United States District Court for the Western District of Arkansas

CLAIM FORM & VERIFICATION

QUALIFICATIONS & INSTRUCTIONS:

Your Claim Form has been submitted successfully.

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
First Name
M.I.
Last Name
Current Mailing Address
Unit/Apt.
City
State
Zip Code
Telephone Number
Email Address

Signature
Date