CLAIM FORM FOR DIRECT PURCHASER SETTLEMENT WITH THE GEO SETTLING PARTIES

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IMPORTANT: PLEASE READ BEFORE COMPLETING THIS CLAIM FORM

NOTE: If you are claiming for more than 20 purchase transactions, please submit a spreadsheet instead of completing the SCHEDULE OF QUALIFYING ALUM PURCHASES in Section III below. Please email the Settlement Administrator at info@LiquidAluminumDirectSettlement.com to request further instructions.

To be eligible for a payment from this Settlement, you must be a Direct Purchaser Settlement Class Member, i.e., you must have purchased liquid aluminum sulfate (“Alum”) in the United States directly from a Defendant from January 1, 1997 through February 28, 2011.

This Claim Form must be completed by Direct Purchaser Settlement Class Members who seek to receive a payment from the partial settlement (“Settlement”) reached between Direct Purchaser Class Plaintiffs and GEO Specialty Chemicals, Inc. (“GEO”), Kenneth A. Ghazey and Brian C. Steppig (collectively, the “GEO Settling Parties”) in the action captioned In Re: Liquid Aluminum Sulfate Antitrust Litigation, Civil Action No. 16-md-2687 (JLL) (JAD) (“Action”).

THIS CLAIM FORM MUST BE COMPLETED AND SUBMITTED NO LATER THAN DECEMBER 17, 2018 IN ORDER TO BE ELIGIBLE TO RECEIVE A SHARE OF THE NET SETTLEMENT FUND IN CONNECTION WITH THE SETTLEMENT.

FAILURE TO SUBMIT YOUR CLAIM FORM BY WILL SUBJECT YOUR CLAIM TO REJECTION AND MAY PRECLUDE YOU FROM BEING ELIGIBLE TO RECEIVE ANY MONEY IN CONNECTION WITH THE SETTLEMENT.

DO NOT MAIL OR DELIVER YOUR CLAIM FORM TO THE COURT, THE PARTIES, OR THEIR COUNSEL. SUBMIT YOUR CLAIM FORM ONLY TO THE SETTLEMENT ADMINISTRATOR BY COMPLETING THE ONLINE FORM BELOW.

If you have questions regarding your Claim Form, please call 1-855-338-6128 or email info@LiquidAluminumDirectSettlement.com. Members of the Direct Purchaser Settlement Class who do not timely and validly seek exclusion from the Direct Purchaser Settlement Class in accordance with the instructions set forth in the Notice will be bound by the judgment entered approving this Settlement as to the GEO Settling Parties regardless of whether they submit a Claim Form.

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TABLE OF CONTENTS

PART I – GENERAL INSTRUCTIONS

PART II – CLAIMANT INFORMATION

PART III – SCHEDULE OF QUALIFYING ALUM PURCHASES

PART IV – SUBMISSION TO JURISDICTION OF THE DISTRICT COURT

PART V – CERTIFICATION

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PART I – GENERAL INSTRUCTIONS

1. It is important that you completely read and understand the Notice. The Notice describes the proposed Settlement with the GEO Settling Parties, how Direct Purchaser Settlement Class Members are affected by the Settlement, and the manner in which the Net Settlement Fund will be distributed if the Settlement is approved by the Court. The Notice also contains the definitions of many of the defined terms (which are indicated by initial capital letters) used in this Claim Form. By signing and submitting this Claim Form, you will be certifying that you have read and that you understand the Notice, including the terms of the releases described therein and provided for herein.

2. To be eligible for a payment from the Settlement, you must be a Direct Purchaser Settlement Class Member. The Direct Purchaser Settlement Class is defined as all persons or entities that purchased Alum in the United States directly from a Defendant from January 1, 1997 through February 28, 2011.¹ Excluded from the Direct Purchaser Settlement Class are (1) Defendants and their respective parents, subsidiaries, and affiliates, and (2) any Direct Purchasers who timely and validly elect to be excluded from the Direct Purchaser Settlement Class.

^{[1] Defendants are General Chemical Corporation, General Chemical Performance Products, LLC, General Chemical LLC, GenTek Inc., Chemtrade Logistics Income Fund, Chemtrade Logistics Inc., Chemtrade Chemicals Corporation, Chemtrade Chemicals US, LLC, Chemtrade Solutions, LLC, C&S Chemicals, Inc., GEO Specialty Chemicals, Inc., USALCO, LLC, Kemira Chemicals, Inc., Southern Ionics, Inc., American Securities LLC, Frank A. Reichl, Brian C. Steppig, Vincent J. Opalewski, Alex Avraamides, Amita Gupta, Kenneth A. Ghazey, Milton Sundbeck, Matthew LeBaron and Scott Wolff.}

3. Important - Please Note: There is a related settlement with entities that purchased Alum from distributors or from other direct purchasers (i.e., “indirect purchasers”). This Claim Form does not pertain to the settlement involving the indirect purchasers. Information about the indirect purchaser settlement with the GEO Settling Parties can be found by visiting the website www.LiquidAluminumSulfate.com . DO NOT SUBMIT THIS CLAIM FORM IF YOU ARE AN INDIRECT PURCHASER.

4. By submitting this Claim Form, you will be making a request to share in the proceeds of the Settlement described in the Notice. IF YOU ARE NOT A DIRECT PURCHASER SETTLEMENT CLASS MEMBER (see definition of Direct Purchaser Settlement Class on page 5 of the Notice or FAQ 6), OR IF YOU SUBMITTED A REQUEST FOR EXCLUSION FROM THE DIRECT PURCHASER SETTLEMENT CLASS, DO NOT SUBMIT A CLAIM FORM. YOU MAY NOT PARTICIPATE IN THE SETTLEMENT IF YOU ARE NOT A DIRECT PURCHASER SETTLEMENT CLASS MEMBER. THUS, IF YOU ARE EXCLUDED FROM THE DIRECT PURCHASER SETTLEMENT CLASS, ANY CLAIM FORM THAT YOU SUBMIT, OR THAT MAY BE SUBMITTED ON YOUR BEHALF, WILL NOT BE ACCEPTED.

5. By submitting a signed Claim Form, you will be swearing to the truth of the statements contained therein and the genuineness of the documents attached thereto, subject to penalties of perjury under the laws of the United States of America. The making of false statements, or the submission of forged or fraudulent documentation, will result in the rejection of your claim and may subject you to civil liability or criminal prosecution.

6. Please be aware that there are specialized companies that may offer to fill out and file your Claim Form in return for a percentage of the value of your claim. Before you sign a contract with one of these companies, you should examine the claim-filing process provided here and decide whether using a specialized company is worth the cost. You can always seek help free of charge from the Settlement Administrator or Interim DPP Lead Counsel.

7. If the Court approves the Settlement, payments to eligible Direct Purchaser Settlement Class Members will be made after the Court grants final approval to the Settlement, after all appeals are resolved, and after the completion of all claims processing. This process could take substantial time. Please be patient.

8. If you have questions concerning the Claim Form, or need additional copies of the Claim Form or the Notice, you may contact the Settlement Administratorby writing to: Liquid Aluminum Sulfate Antitrust Litigation – GEO Direct Purchaser Settlement, PO Box 30097, Philadelphia, PA 19103, emailing: info@LiquidAluminumDirectSettlement.com, or you may download the documents from the website by visiting the Important Documents page. You may also contact Interim DPP Lead Counsel, James E. Cecchi, Esq., Carella, Byrne, Cecchi, Olstein, Brody & Agnello, P.C., 5 Becker Farm Road, Roseland, NJ 07068; 973-994-1700.

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PART II – CLAIMANT INFORMATION

The Settlement Administrator will use the information provided below for all communications regarding this Claim Form. If this information changes, you MUST notify the Settlement Administrator in writing at the address in paragraph 8.

Claimant Names(s): (as the name(s) should appear on check, if eligible for payment). Provide either a First and Last Name or a Company Name (not both) to whom you would like a check made payable if your claim is eligible for payment. If you provide both, we will use your First and Last Name, not the Company Name:

*Required

Are you filing this claim for an individual or company? * Individual Company

First Name *

Last Name *

Company *

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Name of Person the Settlement Administrator Should Contact Regarding this Claim Form:

First Name of Person for Contact *

Last Name of Person for Contact *

Domestic or Foreign Address * Domestic Foreign

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Street Address / P.O. Box: *	Apartment/Suite/Floor Number (If Applicable):
City: *	State: * -- Please Select State -- ALABAMA ALASKA AMERICAN SAMOA ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA NORTHERN MARIANA ISLANDS OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS US VIRGIN ISLANDS UTAH VERMONT VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING
Zip Code: *

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Street Address / P.O. Box: *	Apartment/Suite/Floor Number (If Applicable):
City *	Province *
Postal Code *	Country * -- Select Country -- AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA CÔTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYAN ARAB JAMAHIRIYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTHÉLEMY SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA VIETNAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

Daytime Telephone Number:

Evening Telephone Number:

Email Address *

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PART III – SCHEDULE OF QUALIFYING ALUM PURCHASES

In the purchase section below, please report separately each of your purchases of Alum in the United States directly from a Defendant from January 1, 1997 through February 28, 2011.² In order to qualify as a claim, your purchase(s) must have been billed to and/or shipped to a location in the United States. Foreign transactions where billing and shipping took place outside of the United States do not qualify. Please attach copies of your purchase order(s), invoice(s), or other documentation of your purchase(s). For each purchase of Alum listed below, please include the quantity of Alum purchased, the dollar amount (in U.S. dollars) of purchases made directly from a Defendant during the relevant time period, and the date of each purchase. Amounts should be rounded to the nearest dollar. (Example: $12,345.67 should be entered as $12,346.) Do not include transportation charges, rebates, refunds, credits, etc.

^{[2] Defendants are General Chemical Corporation, General Chemical Performance Products, LLC, General Chemical LLC, GenTek Inc., Chemtrade Logistics Income Fund, Chemtrade Logistics Inc., Chemtrade Chemicals Corporation, Chemtrade Chemicals US, LLC, Chemtrade Solutions, LLC, C&S Chemicals, Inc., GEO Specialty Chemicals, Inc., USALCO, LLC, Kemira Chemicals, Inc., Southern Ionics, Inc., American Securities LLC, Frank A. Reichl, Brian C. Steppig, Vincent J. Opalewski, Alex Avraamides, Amita Gupta, Kenneth A. Ghazey, Milton Sundbeck, Matthew LeBaron and Scott Wolff.}

The Net Settlement Fund will be allocated to eligible Direct Purchaser Settlement Class Members on a pro rata basis based on the total dollar value of each Direct Purchaser Settlement Class Member’s purchase(s) of Alum in the United States directly from a Defendant during the relevant time period to the total dollar value of all valid claims submitted.

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*Required

Purchase 1:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 2:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 3:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 4:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 5:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 6:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 7:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 8:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 9:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 10:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 11:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 12:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 13:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 14:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 15:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 16:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 17:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 18:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 19:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

Check here to add another purchase.

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Purchase 20:

Date of Purchase *
Quantity of Alum Purchased Directly from a Defendant *	Type of Unit * In the event that different quantity measurements appear on your invoice(s)/other record(s), you should default to dry tons if that measurement appears on your invoice(s)/other record(s). Dry tons Wet tons Gallons Dry lbs. Wet lbs. Other	Other *
Dollar Amount (in U.S. dollars) of Alum Purchase (excluding any transportation charges, rebates, refunds, credits, etc.) * $	Proof of Purchase (250Mb Limit)

NOTE: If you are claiming for more than 20 purchase transactions please email the Settlement Administrator at info@LiquidAluminumDirectSettlement.com to request further instructions.

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PART IV - SUBMISSION TO JURISDICTION OF THE DISTRICT COURT

By signing below, you are verifying that:

1. You have provided genuine documentation to support your claim and agree to provide additional information to Interim DPP Lead Counsel or the Settlement Administrator if necessary;
2. You have not assigned or transferred (or purported to assign or transfer) or settled for the same purchases or submitted any other claim for the same purchases of Alum and have not authorized any other person or entity to do so, and know of no other person or entity having done so on your behalf;
3. The information provided in this Claim Form is accurate and complete; and
4. You agree to submit to the jurisdiction of the United States District Court for the District of New Jersey, where this Action is pending, for purposes of resolving any issues related to or arising from your claim.

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PART V - CERTIFICATION

I (We) certify that I am (we are) NOT subject to backup withholding under the provisions of Section 3406 (a)(1)(c) of the Internal Revenue Code because: (a) I am (We are) exempt from backup withholding, or (b) I (We) have not been notified by the IRS that I am (we are) subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me (us) that I am (we are) no longer subject to backup withholding. NOTE: If you have been notified by the IRS that you are subject to backup withholding, click here: I am/we are subject to backup withholding. If you are not subject to backup withholding, do not check the box above.

* UNDER THE PENALTIES OF PERJURY, I (WE) CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME (US) ON THIS CLAIM FORM IS TRUE, CORRECT, AND COMPLETE, AND THAT THE DOCUMENTS SUBMITTED HEREWITH ARE TRUE AND CORRECT COPIES OF WHAT THEY PURPORT TO BE.

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Signature of Claimant *

Company Name *

Capacity of Person Signing *

Prove you're not a robot *