I. Claimant InformationClaimFormNoClaimant Name:* First Last Mailing Address:* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Daytime Phone Number:*Evening Phone Number:*Email Address:* Enter Email Confirm Email II. Purchase InformationPlease provide the information requested in the chart below for each purchase of Milo’s Kitchen Chicken Jerky and/or Milo’s Kitchen Chicken Grillers Home-style Treats made by you in the State of Missouri for personal, household, or family use between March 1, 2011 through January 31, 2013 .Approximate date of purchase (mm/dd/yyyy)* Location of Purchase (include name and address of store where purchased.)*Chicken Jerky Purchased (if applicable)# of PackagesPackage SizeApprox. Price Paid 3.3 Ounce14 Ounce20 Ounce23 Ounce30 OunceChicken Grillers Purchased (if applicable)# of PackagesPackage SizeApprox. Price Paid 3.3 Ounce14 Ounce20 Ounce23 Ounce30 OunceDo you have Proof of Purchase?*YesNoATTACH PROOF Drop files here or Accepted file types: pdf, jpg, jpeg. ** If you are making a claim with proof of purchase (such as a receipt, loyalty card record or other similar documentation), you must provide the proof of purchase with your claim. Claims submitted with proof of purchase are paid differently than claims submitted without proof of purchase. Failure to include proof of purchase with your claim will result in your claim being treated as a “without proof of purchase” claim and subject to the monetary limitations associated with such claim. See Settlement Agreement, Class Notice and settlement website for more information. Submission of false or fraudulent claims may result in, among other things, your claim being rejected in its entirety. III. SignatureSignature Line* I declare under penalty of perjury under the laws of the State of Missouri that between March 1, 2011 through January 31, 2013 I purchased Milo’s Kitchen Chicken Jerky and/or Milo’s Kitchen Chicken Grillers Home-style Treats in the State of Missouri for personal, household, and/or family use, that the information contained in the above chart is correct, and that I am a member of the Settlement Class. Unique IDSignature Date* A claim confirmation email will be sent to the email address provided above once you submit this claim.CommentsThis field is for validation purposes and should be left unchanged.