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ToCF#1026
(3) DECLARATION OF CAUSATION
❏By checking this box, I hereby affirm, under penalty of perjury, that the exclusive and direct
reason for my purchase of the non-Toshiba DVD player was the manifestation of Playback
Incompatibilities on the Toshiba DVD Player at Issue.
AFFIDAVIT UNDER PENALTY OF PERJURY
I attest under the penalties of perjury that:
1. I purchased or acquired the Toshiba DVD Player at Issue on or before October 15, 2004.
2. I am eligible to request the remedy that I am seeking by submitting this Claim Form relating to
the Toshiba DVD Player at Issue.
3. Any documents submitted with this Claim Form are either the originals or true and correct
copies of the originals.
4. I have not requested, and will not request, exclusion from the Settlement Class for the
Toshiba DVD Player at Issue, and I have not previously filed a Claim Form with respect to the
Toshiba DVD Player At Issue, and I will not file in the future a Claim Form with respect to the
Toshiba DVD Player At Issue.
5. I have read and understand the contents of this Claim Form.
6. The statements made in this Claim Form are true and correct to the best of my knowledge. I
realize that if any of them are willfully false, I am subject to punishment under perjury
statutes.
SIGNATURE:
Signature Printed Name Date
IF YOU HAVE ANY QUESTIONS ABOUT THIS CLAIM FORM OR THE SETTLEMENT, PLEASE SEE
THE CLAIMS ADMINISTRATOR'S WEBSITE AT WWW.DVDNOTICE.COM, CALL 1-800-210-5874, OR
SEND YOUR WRITTEN QUESTIONS TO:
DVD Player Claims Administrator
c/o The Notice Company
P.O. Box 778
Hingham, MA 02043
IF YOU DO NOT RETURN A CLAIM FORM POSTMARKED BY MAY 1, 2005, YOUR CLAIM WILL
BE REJECTED AND YOU WILL HAVE WAIVED ALL RIGHTS TO RECEIVE ANY OF THE
SETTLEMENT BENEFITS.