Claim Form

Claimant Information

Please provide contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form.

First Name

Last Name

Address 1

Address 2

City

State

Zip Code

Phone

Email

Purchase Information

Please select the approximate amount of purchases you made from a Subject Vending Machine with a credit, debit, or prepaid card between 2014 and July 9, 2025.*

Note: For reference, there are approximately 250 business days in a calendar year.

Please provide the City and State for where these purchases took place.
You must provide at least one (1) purchase location.

City

State

Payment Election

Please select one of the following payment options.

IMPORTANT NOTES:

For PayPal, Venmo, Zelle payments, if there are any discrepancies, if the account is no longer active, or if the Administrator deems that payment cannot or should not be made based on the provided information, the Administrator will either contact you for clarification or be authorized to default to a Check payment.
If domestic or international payment limits apply to your payment, you may receive more than one transmission or you may default to a Check payment.
Venmo and Zelle payments cannot be made to accounts outside of the United States.
Payments by Check will be made out to the Name on this Form and mailed to the address on this Form.

Attestation & Signature

By submitting a claim form, I hereby request my portion of the settlement. I certify under penalty of perjury that the information provided in the claim form is true and correct to the best of my knowledge.

Signature

Date