POSSIBLE HEPATITIS A EXPOSURE ALLEGED TO ORIGINATE AT THE PAPA... RESTAURANT (STORE #1580) LOCATED AT 8016 -B CAMBRIDGE COMMONS DRIVE,

CLASS ACTION CLAIM FORM AND INSTRUCTIONS
POSSIBLE HEPATITIS A EXPOSURE ALLEGED TO ORIGINATE AT THE PAPA JOHN’S
RESTAURANT (STORE #1580) LOCATED AT 8016 -B CAMBRIDGE COMMONS DRIVE,
CHARLOTTE, NORTH CAROLINA FROM MARCH 28 TO APRIL 7, 2014 AND AS
REFERENCED IN CRYSTAL CAGLER v. PAPA JOHN’S USA, INC., CASE NUMBER 14-CV-303
(U.S. DISTRICT COURT, WESTERN DISTRICT OF NORTH CAROLINA).
If you are a person who:
(1) consumed food or drink from Papa John’s (Store #1580), located at 8016-B Cambridge
Commons Drive, Charlotte, North Carolina on March 28, 29, 30, 31 or April 1, 2, 3, 4, 5, 6, 7,
2014, or
(2) was exposed to someone who had done so;
and you subsequently obtained an immunoglobulin (“IG”) shot or Hepatitis-A vaccination at a public
Health Department clinic or a private health care provider, and you received the shot prior to May 1,
2014, and you wish to participate in the settlement, please complete this form. Please note that you are
not eligible to participate in the settlement if you have previously received compensation from Papa
John’s USA, Inc. or its agents relating to the Hepatitis A incident described above, or if you are an
employee of Papa John’s USA, Inc.
IMPORTANT – to be valid, this form MUST be mailed to the Claims Administrator so that it is
postmarked on or before December 16, 2014.
Please read all of the following instructions carefully before filling out your Claim Form.
1. Please review the Notice of Settlement (the “Notice”). If you do not have the Notice, you may
obtain a copy at www.Charlotte-HEPA.com , or you may request a copy from the Settlement
Administrator, The Notice Company, Inc., at the following address: Charlotte Hepatitis Class
Action, c/o The Notice Company, P.O. Box 778, Hingham, MA 02043
2. Complete and sign the Claim Form. If you have a receipt or other proof of payment for the shot
or vaccination you received, please submit it with your Claim Form.
3. Fill out a SEPARATE claim form for EACH person who obtained an IG shot or Hepatitis A
vaccination. The parent or guardian of a minor child who obtained a shot should fill out a
separate claim form on behalf of each minor child.
4. If you desire an acknowledgement of receipt of your Claim Form, send it by Certified Mail,
Return Receipt Requested.
5. You must submit your Claim Form and any supporting documents by mail to: Charlotte
Hepatitis Class Action, c/o The Notice Company, P.O. Box 778, Hingham, MA 02043
6. Once your Claim Form is received, the Settlement Administrator will review the Claim Form for
compliance and may contact you for additional information regarding your claim.
7. Keep a copy of your completed Claim Form for your records. If your claim is rejected, the
Settlement Administrator will notify you by U.S. Mail or e-mail of the rejection and the reasons
for such rejection.
CLAIMANT INFORMATION
Claimant Name:
Social Security No. (Last 4 digits only):
______________________________________________________________________________
Street Address:
______________________________________________________________________________
City, State, Zip Code:
______________________________________________________________________________
E-mail address (if available):
Phone:
______________________________________________________________________________
TREATMENT INFORMATION
Name of Hospital, Health Department, or Private Medical Facility Where Shot Was Obtained:
______________________________________________________________________________
Address of Facility Identified Above (Street, City, State, and Zip Code):
______________________________________________________________________________
I understand that in order to qualify for payment under this Settlement, I must sign and date the
following certification under penalty of perjury. I certify under penalty of perjury that during the period
from March 28 to April 7, 2014, I consumed food or drink at Papa John’s Store #1580 located at 8016B Cambridge Commons Drive, Charlotte, North Carolina, or was exposed to other persons who had
done so, and that on [insert date] ____________________, 2014, I obtained an IG shot or Hepatitis-A
vaccination at the health care facility identified above (prior to May 1, 2014) and that I am a member of
the settlement class.
_____________________________________
Signature of Claimant
_____________________________
Date
Check the box if you are signing as the parent or guardian of the claimant.
T HIS FORM WILL NOT BE ACCEPTED UNLESS ALL INFORMATION IS PROVIDED , SIGNED BY THE
CLAIMANT ( OR CLAIMANT ’ S PARENT OR GUARDIAN IF APPLICABLE ) AND MAILED SO THAT IT IS
POSTMARKED BY D ECEMBER 16, 2014 TO THE ADDRESS BELOW :
Charlotte Hepatitis Class Action, c/o The Notice Company
P.O. Box 778
Hingham, MA 02043