LBQONE STANDARD CLAIM FORM. LBQ «Barcode» Postal Service: Please do not mark barcode CANADIAN POLYURETHANE FOAM NATIONAL CLASS ACTIONS

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Darcy Jacobs
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1 Canadian Polyurethane Foam Class Action Claims Administrator P.O. Box 4454 Toronto Station A 25 The Esplanade Toronto, ON M5W 4B1 LBQ «Barcode» Postal Service: Please do not mark barcode Claim#: LBQ-«Claim8»-«CkDig» «First1» «Last1» «Addr1» «Addr2» «City», «St» «Zip» «Country» CANADIAN POLYURETHANE FOAM NATIONAL CLASS ACTIONS Must Be Postmarked No Later Than February 6, 2018 STANDARD CLAIM FORM CHANGE OF ADDRESS (ONLY IF DIFFERENT FROM ABOVE) Primary Address Primary Address Continued City Province Postal Code Foreign Province Foreign Postal Code Foreign Country Name/Abbreviation Complete this Standard Claim Form to receive a payment from class action settlements totaling more than $38 million. Your claim must be postmarked by February 6th Do I qualify as a Class Member? You are automatically a Class Member and can complete a claim form if you : live in Canada now or you lived in Canada between January 1, 1999 and January 10, 2012; and bought Flexible Polyurethane Foam, Foam Products or Carpet Underlay in Canada for personal, commercial, or manufacturing use between January 1, 1999 and January 10, Flexible Polyurethane Foam means: slabstock flexible polyurethane foam, except for Molded Foam and Technical Foam. Foam Products means: bed mattresses and upholstered office chairs, armchairs, two-seat sofas, three-seat sofas and sectional sofas, made in Canada and containing Flexible Polyurethane Foam. Carpet Underlay means: carpet pad, carpet cushion, or carpet underlay made in Canada of scrap Flexible Polyurethane Foam bonded together by various chemicals into a padding material. Which form should I complete? Complete this Standard Claim Form if you purchased large quantities of Carpet Underlay, Flexible Polyurethane Foam and/or Foam Products for personal/business use, for manufacturing purposes or for commercial distribution/resale. Complete the Simplified End Consumer Claim Form to claim a payment of $20 if you purchased only a single/small quantity of new Carpet Underlay and/or Foam Products for personal/business use and not for commercial resale. Family members living in the same household must pool their purchases together and submit a single End Consumer Claim. Compensation payable in respect of a household claim will be issued to the person filing the claim on behalf of the household. *LBQONE* 1 FOR CLAIMS PROCESSING ONLY OB CB DOC LC REV RED A B

2 How do I submit my claim form? You can submit a claim form online at or submit a paper form to the following address, postmarked no later than February 6th, 2018: Canadian Polyurethane Foam Class Action Claims Administrator P.O. Box 4454, Toronto Station A, 25 The Esplanade, Toronto, ON M5W 4B1 How can I get more information? More information about the settlements is available in the Notice. If you did not receive the Notice or have additional questions, please contact the Claims Administrator toll free at 1 (888) or visit Please Print in the Boxes Below (Do Not use Red Ink or Pencil) PART I: CLAIMANT INFORMATION (FOR INDIVIDUALS/FAMILIES) Address Telephone Please note family members living in the same household must pool their consumer purchases together and submit a single End Consumer Claim. If you are filing this claim on behalf of a household, please enter the number of family members in your household. PART II: CLAIMANT INFORMATION (FOR BUSINESS OR GOVERNMENT ENTITY) Business Name or Government Entity Contact Name Title Address 1 Address 2 City Province Postal Code Address Telephone Number of employees (including yourself) *LBQTWO* 2

3 General Instructions PART III: PURCHASER CATEGORIES You can claim for purchases you made in any or all of the following categories on this Claim Form: End Consumer Claims Manufacturers Claims Resellers Claims Make an End Consumer Claim if you bought Carpet Underlay and/or Foam Products in Canada between January 1, 1999 and January 10, 2012 for your own household/business use and not for commercial resale. End Consumers include individuals, households, businesses ranging from the smallest to the largest in Canada, and governmental entities. Family members living in the same household must pool their consumer purchases together and submit a single End Consumer Claim. Compensation payable in respect of a household claim will be issued to the person filing the claim on behalf of the household. Make a Manufacturers Claim if you bought Flexible Polyurethane Foam in Canada between January 1, 1999 and January 10, 2012 to manufacture products that incorporate Flexible Polyurethane Foam for commercial resale. Manufacturers Claims include purchasers of Flexible Polyurethane Foam in Canada for manufacture of any products which contain Flexible Polyurethane Foam including for the manufacture of Carpet Underlay. Make a Resellers Claim if you bought Flexible Polyurethane Foam and/or Foam Products and/or Carpet Underlay in Canada between January 1, 1999 and January 10, 2012 for commercial resale (without modification). Depending on the category selected, you will be required to provide the number and/or the $ value of your purchases between January 1, 1999 and January 10, We require some documentation to prove your purchases. We recognize that, due to the time lag since you made these purchases, you may no longer have receipts. We will accept as proof of purchase documents which either directly show your purchases or from which your purchases can be calculated or extrapolated. Some examples are purchase orders, invoices, historical accounting records, records showing the budgets for Flexible Polyurethane Foam/Foam Products/Carpet Underlay purchases, or other related documents. The proof of purchase submitted should correspond to the total amount claimed in each applicable Section. PART IV END CONSUMER CLAIMS I/we purchased Foam Products for my/our own personal/business use and not for commercial resale. Report the total number of Foam Products (other than Carpet Underlay) purchased in Canada for personal/business use and not for commercial resale from January 1, 1999 to January 10, Single/Twin Mattresses Double Mattresses King Mattresses Two-seater Sofas Queen Mattresses Three-seater Sofas Sectional Sofas (greater than 3 seats) 4 seats: 5 seats: 6 seats: 7 seats Other (specify) Upholstered Armchairs Upholstered Office Chairs I/we purchased Carpet Underlay for my/our own personal/business use and not for commercial resale. Report the total $ value of Carpet Underlay purchased in Canada for personal/business use and not for commercial resale from January 1, 1999 to January 10, $. *LBQTHREE* 3

4 PART V MANUFACTURER CLAIMS I/we purchased Flexible Polyurethane Foam (including scrap) to manufacture Carpet Underlay. Report the total $ value of Flexible Polyurethane Foam (including scrap) purchased in Canada for manufacture of Carpet Underlay per year from January 1, 1999 to January 10, I/we purchased Flexible Polyurethane Foam to manufacture products other than Carpet Underlay. Report the total $ value of Flexible Polyurethane Foam purchased in Canada for manufacture of products (other than Carpet Underlay) per year from January 1, 1999 to January 10, PART VI RESELLERS CLAIMS I/we purchased Flexible Polyurethane Foam for commercial resale (without modification). Report the total $ value of Flexible Polyurethane Foam purchased in Canada for commercial resale (without modification) per year from January 1, 1999 to January 10, Single/Twin Mattresses Double Mattresses King Mattresses Two-seater Sofas Queen Mattresses Three-seater Sofas Sectional Sofas (greater than 3 seats) 4 seats: 5 seats: 6 seats: 7 seats Other (specify) Upholstered Armchairs Upholstered Office Chairs *LBQFOUR* 4

5 I/we purchased Carpet Underlay in Canada for commercial resale (without modification). Report the total $ value of Carpet Underlay purchased in Canada for commercial resale (without modification) per year from January 1, 1999 to January 10, I/we purchased Flexible Polyurethane Foam for commercial resale (without modification). Report the total $ value of Flexible Polyurethane Foam purchased in Canada for commercial resale (without modification) per year from January 1, 1999 to January 10, PART VII. VERIFICATION (INDIVIDUALS/FAMILIES ONLY) I/we verify that I and the family members who currently reside with me purchased Carpet Underlay and/or Foam Products in Canada for personal or business use and not for commercial resale between January 1, 1999 and January 10, I/we understand, verify and agree to the following: The Claims Administrator may contact me as the Claims Administrator deems appropriate for more information about my claim. The present claim relates to Carpet Underlay or Foam Product purchases for which I/we have not been compensated and have given no release as part of other proceedings or settlements. No other family member currently residing with me has nor will submit a separate End Consumer Claim for compensation. I am at least 18 years old. I/we reside(d) in Canada now or at the time of purchase of the Carpet Underlay or Foam Products. I/we have provided a proof of purchase for the Carpet Underlay or the Foam Product purchases for which I/we are making a claim. *LBQFIVE* 5

6 PART VIII. VERIFICATION (BUSINESS OR GOVERNMENT ENTITY ONLY) I/we verify that the business or government entity who hereby requests money has purchased Flexible Polyurethane Foam, Foam Products and/or Carpet Underlay in Canada between January 1, 1999 and January 10, I/we understand, verify and agree to the following: The Claims Administrator may contact me as the Claims Administrator deems appropriate for more information about my claim. The present claim relates to Flexible Polyurethane Foam, Foam Products and/or Carpet Underlay purchases for which the business or government entity who hereby requests money have not been compensated and have given no release as part of other proceedings or settlements. No other claim has been or will be submitted on behalf of the business or government entity who hereby requests money. I am at least 18 years old. The business or government entity who hereby requests money reside(d) in Canada now or at the time of purchase of the Flexible Polyurethane Foam, Foam Products and/or Carpet Underlay. I/we have provided proof of purchase for the Flexible Polyurethane Foam, Foam Products and/or Carpet Underlay purchases for which I/we are making a claim. PART IX: DECLARATION By submitting this claim I solemnly declare that the information provided in this Claim Form is true and correct and that the purchases in this Claim Form have not been submitted for any other compensation. Executed this day of in (Month/Year) (City/Province/Country) (Sign your name here) (Type or print your name here) (Position) ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT OF TIME. THANK YOU FOR YOUR PATIENCE. Reminder Checklist: 1. Please sign the above declaration. 2. Remember to attach supporting documentation. 3. Keep a copy of your claim form and all supporting documentation for your records. 4. If you move, please send the Claims Administrator your new address. The Claims Process The Court-approved Distribution Protocol and Administration Protocol govern the Claims Process. Class Members should review the Distribution Protocol found at for the complete rules or contact the Claims Administrator toll free at 1 (888) The Claims Administrator is: RicePoint Administration Inc. of London, Ontario. Class Counsel is: Strosberg Sasso Sutts LLP of Windsor, Ontario; Law Office of Andrew J. Morganti of Toronto, Ontario; Camp Fiorante Matthews Mogerman of Vancouver, British Columbia; Branch MacMaster LLP of Vancouver, British Columbia; and Belleau Lapointe s.e.n.c.r.l. of Montreal, Quebec. Privacy Statement All information provided by the Claimant is collected, used, and retained by the Claims Administrator, Class Counsel and their agents pursuant to the Personal Information Protection and Electronic Documents Act (PIPEDA) for the purposes of administering the Canadian Polyurethane Foam Class Action Settlement Agreements, including evaluating the Claimant s eligibility status under the Settlement Agreements. The information provided by the Claimant is strictly private and confidential and will not be disclosed without the express written consent of the Claimant, except in accordance with the Settlement Agreements, distribution protocol or orders of the courts. *LBQSIX* 6

CANADIAN SRAM NATIONAL CLASS ACTIONS CLAIM FORM. Canadian SRAM Class Action Claims Administrator P.O. Box 3355 London, ON N6A 4K3

CANADIAN SRAM NATIONAL CLASS ACTIONS CLAIM FORM Canadian SRAM Class Action Claims Administrator P.O. Box 3355 London, ON N6A 4K3 Tel: 1 (866) 982-8281 Must Be Postmarked No Later Than June 29, 2016 Complete