Claim Form

Your claim form United States District Court
must be submitted Middle District of Florida

online or WAL
postmarked by: Kukorinis v. Walmart Inc.
June 5, 2024 Case No. 8:22-CV-02402-VMC-TGW
CLAIM FORM INSTRUCTIONS
1. You may submit your Claim Form online at www.WalmartWeightedGroceriesSettlement.com or by U.S. Mail to
the following address: Walmart Weighted Groceries Settlement, c/o Claims Administrator, 1650 Arch Street, Suite
2210, Philadelphia, PA 19103.
2. Please type or write your responses legibly.
3. Please keep a copy of your Claim Form and any supporting materials you submit. Do not submit your only copy
of the supporting documents. Materials submitted will not be returned.
4. If your Claim Form is incomplete or missing information, the Claims Administrator may contact you for additional
information. If you do not respond, the Claims Administrator will be unable to process your claim, and you will
waive your right to receive money under the Settlement.
5. Each Class Member can only submit one Claim Form. The Claims Administrator will limit the number of payments
per household absent sufficient documentation or proof of separate purchases by individuals residing at the same
address.
6. You may only submit a Claim for Purchases of Weighted Goods and Bagged Citrus from October 19, 2018
through and including January 19, 2024. Weighted Goods are sold-by-weight meat, poultry, pork, and seafood
products. Bagged Citrus are organic oranges, grapefruit, tangerines, and navel oranges sold in bulk in mesh or
plastic bags. Product descriptions and a searchable list of UPC Codes for the Weighted Goods and Bagged Citrus
are on the Settlement Website, www.WalmartWeightedGroceriesSettlement.com.
7. Only purchases of Weighted Goods and/or Bagged Citrus that were made in person at a Walmart retail store,
supercenter, or neighborhood market in the United States and/or Puerto Rico are eligible. Purchases of Weighted
Goods and Bagged Citrus products that were done online, for resale, or that were returned, are not part of
the Litigation and Settlement and are not eligible for payment.
8. If you have any questions, please contact the Claims Administrator: by email at
Info@WalmartWeightedGroceriesSettlement.com; or by mail at the address listed above; or by calling 1-833-987-
9998.
9. You must notify the Claims Administrator if your email, mobile number, and/or address changes. If you do
not, you may not receive your payment.
10. DEADLINE -- Your claim must be submitted online by June 5, 2024. Claim Forms submitted by mail must
be mailed to the Claims Administrator postmarked no later than June 5, 2024.
The amount that a Settlement Class Member will receive depends on the number of people who submit valid
Claim Forms because all amounts are subject to a potential pro rata increase or decrease.
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QUESTIONS? Visit www.WalmartWeightedGroceriesSettlement.com or call toll-free 1-833-987-9998
online or WAL
CLAIM FORM
I. YOUR CONTACT INFORMATION AND MAILING ADDRESS
Provide your name and contact information below.
First Name Last Name
Street Address
City State Zip Code
Email Address Mobile Phone Number
IF YOU RECEIVED AN EMAIL, PROVIDE THE FOLLOWING FROM THE EMAIL:

Notice ID: Confirmation Code:
2
online or WAL
II. BAGGED CITRUS AND/OR WEIGHTED GOODS PURCHASED
Select from one of the following two options:

* The dollar amounts shown below are not guaranteed; they are subject to a potential pro rata increase or decrease
depending on the number of people who submit valid Claim Forms.
OPTION 1
I do not have receipts, proof of purchase, or other documentation but attest to having Purchased the following
number of Weighted Goods and/or Bagged Citrus in-person in a Walmart Store from October 19, 2018
through January 19, 2024 (select one only):
up to 50 Weighted Goods and/or Bagged Citrus to receive $10.00*
between 51 and 75 Weighted Goods and/or Bagged Citrus to receive $15.00*
between 76 and 100 Weighted Goods and/or Bagged Citrus to receive $20.00*
101 or more Weighted Goods and/or Bagged Citrus to receive $25.00*
Describe the types of Weighted Goods and/or Bagged Citrus you Purchased, and identify the Years Purchased:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
OPTION 2
I have receipts, proof of purchase, or other documentation that documents (a) each Weighted Good and/or
Bagged Citrus product I Purchased in-person in a Walmart Store from October 19, 2018 through January
19, 2024, and (b) the amount I paid for each Weighted Good and/or Bagged Citrus Purchased.
Enter the number of Weighted Goods and/or Bagged Citrus you are providing documentation for:
_________
Enter the total amount paid for the Weighted Goods and/or Bagged Citrus that you submitted documentation
for: $_____________. [You may receive 2% of this amount capped at $500.00*]
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online or WAL
III. PAYMENT SELECTION
Please select from one of the following payment options:
Venmo - Enter the mobile number associated with your Venmo account: __ __ __-__ __ __-__ __ __ __
Zelle - Enter the mobile number or email address associated with your Zelle account:
Mobile Number: __ __ __-__ __ __-__ __ __ __ or Email Address: ___________________________________
Virtual Prepaid Card - Enter your email address: ____________________________________
Physical Check - Payment will be mailed to the address provided in Section I above.
IV. VERIFICATION AND ATTESTATION UNDER PENALTY OF PERJURY
By signing below and submitting this Claim Form, I hereby swear under penalty of perjury that I am the person
identified in Section I and the information provided in this Claim Form, including any accompanying supporting
documentation, is true and correct, this is the only Claim Form that I have submitted, and nobody has submitted
another claim in connection with this Settlement on my behalf.
I further understand, acknowledge, and agree that the amount I will receive shall be calculated in accordance
with the terms of the Settlement Agreement and I am subject to the terms of the Settlement Agreement,
including the release of claims as more fully described in the Settlement Agreement.
___________________________________ Date:
Your signature MM DD YYYY
___________________________________
Your name
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Claim Form

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Your claim form United States District Court

must be submitted Middle District of Florida

CLAIM FORM INSTRUCTIONS

2. Please type or write your responses legibly.

I. YOUR CONTACT INFORMATION AND MAILING ADDRESS

Provide your name and contact information below.

First Name Last Name

City State Zip Code

Email Address Mobile Phone Number

IF YOU RECEIVED AN EMAIL, PROVIDE THE FOLLOWING FROM THE EMAIL:

II. BAGGED CITRUS AND/OR WEIGHTED GOODS PURCHASED

Select from one of the following two options:

III. PAYMENT SELECTION

Please select from one of the following payment options:

Mobile Number: - - or Email Address: ___________________________________

Virtual Prepaid Card - Enter your email address: ____________________________________

IV. VERIFICATION AND ATTESTATION UNDER PENALTY OF PERJURY

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