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*2814* *CFW* *1-2*
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II you paid a subscription Iee to rent DVDs Irom Netfix any time Irom May 19, 2005 to September 2, 2011, you
will be eligible to receive benefts Irom a Settlement with Wal-Mart Stores Inc. and Walmart.com USA LLC.
You need to submit this Claim Form iI you want to receive a cash payment or a giIt card. The deadline to fle
claims is February 14, 2012.
The amount oI the giIt card or cash payment will be determined based on a Iormula contained in the Settlement
Agreement and in the notice you received. Additional inIormation regarding the Iormula and the Settlement
can be Iound at www.OnlineDVDclass.com.
To claim a gift card you may submit the Claim Form by mail or online at www.OnlineDVDclass.com.
II submitting by U.S. Mail, print and complete this Claim Form and mail it to the Iollowing address
postmarkedonorbeIoreFebruary 14, 2012:
Claims Administrator
PO Box 2602
Faribault, MN 55021-9602
To claim a cash payment, you must complete this Claim Form and mail it to the Iollowing address postmarked
onorbeIoreFebruary 14, 2012:
Claims Administrator
PO Box 2602
Faribault, MN 55021-9602
You cannot fle an online claim Ior a cash payment.
C L S C 1 I I 1 S
*2-2* *CFW* *2814*
*0000000000*
SLC1ICN I CCN1AC1 INICkMA1ICN
Name:(First/Last)
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N (primary)
N
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SLC1ICN II NL1ILIx SU8SCkI1ICN
S M N
SLC1ICN III AWAkD SLLLC1ICN
Please tell us whether you preIer to receive an electronic GiIt Card or a cash payment. You may not request
both. II you are requesting a cash payment, you must also provide the last Iour digits oI your social security
number. You can give your giIt card to someone else but it cannot be resold.
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Last Four Digits oI your Social Security Number (for cash payments only):XXX - XX -
SLC1ICN IV AIIIkMA1ICN
I hereby aIfrm, under penalty oI perjury, that the inIormation I have provided in this Claim Form is true and correct
to the best oI my knowledge and this is the only Netfix Claim Form that I have submitted. I Iurther understand,
acknowledge, and agree that I am eligible to receive only ONE payment Irom this Settlement based on my subscription
to a Netfix Online DVD service. I Iurther understand, acknowledge, and agree that the amount I will receive shall be
calculated according to the terms oI the Settlement Agreement and subject to the terms oI the Settlement Agreement,
including the release oI claims.
Date:
/ /
Signature: