You must accurately complete all required portions of this Claim Form and submit the Claim Form under penalty of perjury.
YOU MUST SUBMIT YOUR CLAIM FORM NO LATER THAN JUNE 6, 2019.
Provide your name and contact information below.
This information will be used to deliver your Settlement Benefit and communicate with you if any problems arise with your claim. It is your responsibility to notify the Settlement Notice & Claims Administrator of any changes to your contact information after the submission of your Claim Form.
Your claim reflects you purchased $500 or more of products (exclusive of returns) from Burlington stores located in New Jersey between June 26, 2011 and May 22, 2017. Per the terms of the settlement agreement you are required to provide with this Claim Form proof of qualifying purchases. Acceptable proofs of your purchases include (a) receipt(s) clearly showing the date of purchase(s) and the total of the purchase(s), or (b) a credit or debit card transaction record clearly showing the date of purchase(s) and the total of the purchase(s). The proofs of purchase must include sufficient information to allow Burlington to verify the purchase(s).
Your file(s) will be uploaded once you click "Submit" at the end of this form
Please confirm the email address to which you would like the Purchase Certificate(s) delivered.
I have received notice of the class action Settlement in this case and I am a class member as described in the notice. I agree to release all claims against Burlington as described in Section 2.8 of the Settlement Agreement.
I submit to the jurisdiction of the Superior Court of Camden County, New Jersey with regard to my claim and for purposes of enforcing the release of claims stated in the Settlement Agreement. I am aware that I can obtain a copy of the full notice and Settlement Agreement at www.burlingtonnjsettlement.com or
by writing the Claims Administrator at the email address Burlington@AdministratorClassAction.com or the postal address 1650 Arch Street, Suite 2210, Philadelphia, PA 19103. I agree to furnish additional information to support this claim if required to do so.
(Type your name here to electronically sign your Claim Form)