Claim Form

Only Class Members who did not receive an email with a Notice ID and PIN are required to submit a Claim Form.

Claimant Information

Please provide contact information below. You must notify the Claims Administrator if your contact information changes after you submit this Claim Form.

First Name:*

Last Name:*

Address 1:*

Address 2:

City:*

State:*

Zipcode:*

Phone:*

Email:*

Payment Election

IMPORTANT NOTES:

For E-Mastercard, PayPal, Venmo, Zelle payments, if there are any discrepancies, if the account is no longer active, or if the Administrator deems that payment cannot or should not be made based on the provided information, the Administrator will either contact you for clarification or be authorized to default to a Check payment.
If domestic or international payment limits apply to your payment, you may receive more than one transmission or you may default to a Check payment.
Venmo and Zelle payments cannot be made to accounts outside of the United States.
Payments by Check will be made out to the Name on this Claim Form and mailed to the address on this Claim Form.

Attestation & Signature

By signing below and submitting this Claim Form, I declare under penalty of perjury under the laws of the state of California that I purchased one or more 12 oz canisters of 365 Organic Hot Cocoa Rich Chocolate Flavor Mix or 365 Everyday Value Organic Hot Cocoa Rich Chocolate Flavor Mix from a Whole Foods Market store located within California or, if purchased remotely (such as online), while present in California between November 3, 2017 and March 13, 2025.

Signature:*

Date: