SUPERIOR COURT OF THE STATE OF CALIFORNIA FOR THE COUNTY OF SAN BERNARDINO Amiri v. My Pillow — Case No. CIVDS1606479 CLAIM FORM Subject to the terms of the Settlement Agreement, and pending final approval by the Court, to request a settlement payment, please complete this form and return it by December 26, 2016.

CONTACT INFORMATION

(Please type or print the following information): Fill in the following blanks with complete information.

Name:	_____________________________________________	_____	_____________________________________________
	First Name	MI	Last Name

Address:	________________________________________________________________________________________________
	Address 1
	________________________________________________________________________________________________
	Address 2

	__________________________________________________	_______	_______________-_______________
	City	State	Zip Code              Zip4 (optional)

Daytime Telephone (________)_________-______________	Evening Telephone (________)_________-______________
Email Address: _____________________________________________@__________________________________________._____________

CLAIM INFORMATION

To request a $5 refund, please return your My Pillow product, provide the original purchase receipt, or sign this Claim Form under penalty of perjury. If you purchased three or more My Pillow products during your initial purchase and you write "Three+" on your original purchase receipt that you return with your Claim Form, you may be eligible to receive an additional benefit of up to $5, depending on the number of people who submit a Claim Form. There is a maximum of one Claim Form per household.

CERTIFICATION

I swear under penalty of perjury of the laws of the United States that I purchased _____ My Pillow products between April 26, 2012 and October 13, 2016 and that all the information on this form is true and correct to the best of my knowledge.

_____________________________________	_____________________________________
Signature	Date

Instructions

Complete the Contact and Claim information above.

Sign and date the Claim Form

Submit this completed and signed Claim Form to:

My Pillow Settlement
P.O. Box 1561
West Palm Beach, FL 33402
1-877-595-9314

REVIEW AND DETERMINATION OF CLAIMS: The Claims Administrator will review all claim forms that are postmarked on or before December 26, 2016. Claim forms that are not timely submitted will be rejected. Invalid claim forms and illegible claim forms may be rejected. The Claims Administrator is entitled to confirm information supplied in claim forms to determine eligibility. Visit to www.mypillowsettlement.com for further information on the Settlement.