STORES ONLINE CLAIM FORM OFFICE OF THE ATTORNEY GENERAL CONSUMER PROTECTION DIVISION Please review this form BEFORE filling it out. Please fill out the form completely. Return this form postmarked by September 21, 2009. Feel free to make copies of this form or, if necessary, contact our office for additional forms. Please return this claim form with any additional pages, if necessary, and copies (no originals, please) of documents you feel help explain or substantiate your claim. Please do your best to provide complete information. If you cannot provide all of the information we are requesting, it will not necessarily eliminate your claim. However, we may need to obtain additional information from you, which could delay consideration of your claim. NOTE: IT IS IMPORTANT TO FILL OUT THE THIS FORM COMPLETELY AND TO MAKE A COPY FOR YOUR RECORDS. STATEWIDE TOLL FREE 1-800-551-4636 (1-800-833-6384 for hearing impaired) CLAIM INFORMATION Claimant Information Please Print or Type Name _____________________________________________________________________________ Last First Middle Initial Address:_______________________________________________________________________________________ City: ________________ State___________ Zip____________ Phone: (____) __________(Day) (____) __________ (Evening) E-mail address: ___________________________ Have you filed a complaint about Stores Online with the Attorney General’s Office before? Yes No If Yes, list the file number _______________________ Stores Online or referred to product or service you are filing a claim for: Date of Purchase: ___/___/____ Purchase Price: $______ Amount Paid: $______ Amount Owe: $______ Third-party product or service you are filing a claim for (e.g., coaching): Name of third-party: Date of Purchase: ___/___/____ Purchase Price: $______ Amount Paid: $______ Amount Owe: $______ Have you received a refund, account credit, or other payment from Stores Online, your credit card company, or from any other source related to the product or service you have identified on this claim form? If YES identify amount: Yes $__________ No Have you been or are you currently a party to any legal action against Stores Online where amounts were refunded to you? If YES identify amount: Yes $__________ No Have you suffered a negative credit report due to your transaction with Stores Online or third-party referred by Stores Online. Yes No I don’t know 12. Please be aware that your claimed amount will be subject to verification and a representative of our office may need to contact you to ask for clarifying information. By signing this document I attest that I was never able to get an e-commerce site operational using Stores Online’s products or services and/or the services of third parties referred by Stores Online, and I agree that by accepting any offered restitution, my contract will be rescinded and all services provided or offered by Stores Online and/or the third party will no longer be available to me. I understand that my claim and the related documents will become a “public record” and under state law can be subject to a public records disclosure request and thus be seen by other people. I declare, under penalty of perjury under the laws of the State of Washington, that the information contained in this claim is true and accurate, and that any documents attached are true and accurate copies of the originals. Signature Date City and State where signed __________________________________ ___/___/____ ____________________________________ Please return completed Claim Form to: Stores Online Restitution Program Office of the Attorney General 800 Fifth Avenue, Suite 2000 Seattle, WA 98104-3188 1-800-551-4636 .(1-800-833-6384 for hearing impaired) This form must be returned post-marked no later than September 21, 2009 Go to http://www.atg.wa.gov/Settlements/default.aspx to find more information, including a Q&A, regarding the Stores Online Claims Process.