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EXHIBIT C-1
CLAIM FORM AND INSTRUCTIONS
Hornbeck, et al. v. Orscheln Farm and Home, LLC, et al.,
Case Number 18-00941-cv-W-BP (W.D. Mo.)
Please read all of the following instructions carefully before filling out your Claim Form.
1. Please review the Long Form Class Notice (the “Notice”) that you received when you
complete your Claim Form. The Long Form Class Notice is available on the settlement website
at [WEBSITE] or by calling the Settlement Administrator at [INSERT SETTLEMENT PHONE
NUMBER].
2. Under the terms of the Settlement in this class action lawsuit, you may be entitled to
relief based on your purchase(s) of the following products during the stated Class Period:
Products Package Size Class Period
MileMaster 303 Tractor
Hydraulic Fluid
3/2 gal. January 23, 2017 to present
MileMaster 303 Tractor
Hydraulic Fluid
5 gal. May 25, 2013 to present
MileMaster 303 Tractor
Hydraulic Fluid
55 gal. May 25, 2013 to present
H-K 303 Tractor Transmission
Hydraulic Fluid
3/2 gal. May 25, 3013 to April 30, 2016
H-K 303 Tractor Transmission
Hydraulic Fluid
5 gal. May 25, 2013 to March 21, 2019
Orscheln Premium 303 Tractor
Hydraulic & Transmission
Fluid
5 gal. September 3, 2014 to August 16, 2017
SuperTech 303 Tractor
Hydraulic Oil
5 gal. February 17, 2016 to February 10,
2018
If you wish to receive relief under the Settlement Agreement, you must timely complete and
submit Part A of the Claim Form to receive a monetary award based on your purchase(s)
of the products listed above (the “303 THF Products”) during the relevant Class Periods.
The Part A monetary award is for reimbursement based on your 303 THF Product purchases and
is estimated to be a minimum of $18 for each 3/2-gallon jug of Product you purchased during the
Class Period, $27 for each 5-gallon bucket, and $200 for each 55-gallon drum.
3. Under the Settlement Agreement, you also may be entitled to a Part B award for
reimbursement for the cost of any repairs, parts, and/or specific equipment damage that you
contend resulted, in whole or in part, from your use of a 303 THF Product during the relevant
Class Period. If you wish to receive this relief, you must timely complete and submit Parts
A and B of the Claim Form. Be sure to attach all supporting documents as well as any further
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 1 of 9
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information you have supporting your claim for additional funds due to alleged equipment
losses, repairs and/or parts purchases.
4. You are not entitled to reimbursement under this Settlement if you were already
reimbursed for your purchases or for repairs, parts, or damage to specific equipment that you
contend was caused by your use of the above listed 303 Tractor Hydraulic Fluid Products during
the Class Period.
5. If you would like an acknowledgment of receipt of your Claim Form, send it by Certified
Mail, Return Receipt Requested.
6. To submit the Claim Form, you must do one of the following: (i) complete an electronic
claim form and submit it via the settlement website at [WEBSITE] on or before [INSERT BAR
DATE]; or (ii) complete a paper Claim Form and send it via fax to [INSERT SETTLEMENT
FAX NUMBER], via United States mail, postage prepaid to [INSERT SETTLEMENT
MAILING ADDRESS], or via e-mail to [INSERT SETTLEMENT E-MAIL ADDRESS] by
[INSERT BAR DATE].
7. Once your Claim Form is received, the Settlement Administrator will review the Claim
Form for compliance. Your claim for monetary relief may be rejected for failure to complete the
information requested in the Claim Form or for failure to provide sufficient supporting
documentation. The Claims Administrator may contact you for additional information.
8. 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.
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 2 of 9
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CLAIM INFORMATION – PART A
Claimant Name: Phone Number:
_____________________________________________ ________________________
Street Address: Email Address:
_____________________________________________ ________________________
City, State, Zip Code:
_____________________________________________
Products Package Size Class Period
MileMaster 303 Tractor
Hydraulic Fluid
3/2 gal. January 23, 2017 to present
MileMaster 303 Tractor
Hydraulic Fluid
5 gal. May 25, 2013 to present
MileMaster 303 Tractor
Hydraulic Fluid
55 gal. May 25, 2013 to present
H-K 303 Tractor Transmission
Hydraulic Fluid
3/2 gal. May 25, 3013 to April 30, 2016
H-K 303 Tractor Transmission
Hydraulic Fluid
5 gal. May 25, 2013 to March 21, 2019
Orscheln Premium 303 Tractor
Hydraulic & Transmission
Fluid
5 gal. September 3, 2014 to August 16, 2017
SuperTech 303 Tractor
Hydraulic Oil
5 gal. February 17, 2016 to February 10,
2018
List your purchases of any 303 THF Products purchased during the stated Class Period.
Do not list any purchases that you returned to the store after purchase.
Product
Purchased
Date
Purchased
Store (Name and Location) Product Size
(3/2 gal.; 5
gal.; 55 gal.)
Qty. Payment
Method
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 3 of 9
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List the equipment in which you used the Products during the stated Class Period:
Type of Equip. Year Make Model
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury the foregoing is true and correct
and that the above-described purchases were not for the purpose of resale to others.
Signature: _______________________________ Date: ____________________
Print Name: ____________________________
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 4 of 9
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CLAIM INFORMATION – PART B
Complete Part B of this Claim Form only if you seek reimbursement for any repairs, parts,
and/or specific equipment damage that you contend resulted, in whole or in part, from your
use of the following products during the stated Class Period:
Products Package Size Class Period
MileMaster 303 Tractor
Hydraulic Fluid
3/2 gal. January 23, 2017 to present
MileMaster 303 Tractor
Hydraulic Fluid
5 gal. May 25, 2013 to present
MileMaster 303 Tractor
Hydraulic Fluid
55 gal. May 25, 2013 to present
H-K 303 Tractor Transmission
Hydraulic Fluid
3/2 gal. May 25, 3013 to April 30, 2016
H-K 303 Tractor Transmission
Hydraulic Fluid
5 gal. May 25, 2013 to March 21, 2019
Orscheln Premium 303 Tractor
Hydraulic & Transmission
Fluid
5 gal. September 3, 2014 to August 16, 2017
SuperTech 303 Tractor
Hydraulic Oil
5 gal. February 17, 2016 to February 10,
2018
1. Plaintiffs allege that use of the 303 Tractor Hydraulic Fluid products listed above (“the
303 THF Products”) can cause damage to tractors and other equipment in which it is used.
Defendants deny these allegations and deny that the 303 THF Products cause damage to tractors
or other equipment. As part of this Class Settlement, Class Members are entitled to submit
claims for reimbursement for repairs, parts, and specific equipment damage that the Class
Member contends resulted, in whole or in part, from use of these Products during the Class
Period.
2. The repairs, parts, and specific equipment damage may include, without limitation,
repairs, parts and equipment purchases required to remedy damage to seals, pumps, filters, gears,
clutch and brake systems, power take-off (PTO) systems and losses incurred as a result of
equipment being damaged beyond reasonable repair as a result of damage and increased or
excessive wear resulting from use of the 303 THF Products. Such increased wear and damage
may include, without limitation, scratching, corrosive wear, rippling, ridging, pitting, spalling
and scoring of the gears and metal components, seal damage, spiral gear damage, metal abrasion,
corrosion, surface wear, clutch wear and breakage, wet brake damage, pump failure, leakage, and
damage from deposits, sludging and thickening.
3. Consequential or other losses (such as down time) that might have been incurred as a
result of equipment being damaged are not recoverable under the Settlement Agreement. Other
examples of damage and loss not covered by this Settlement include damage caused by
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 5 of 9
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negligence of the owner/operator of the equipment; damage caused by the use of a 303 THF
Product prior to the start date of the relevant Class Period; damage caused by the use of any
tractor hydraulic product not listed above; and damage caused by normal wear and tear. If the
damage to equipment resulted in part from any of these causes and in part from the 303 THF
Product’s use, then a claim would be appropriate.
4. To recover losses from this Repairs/Parts/Specific Equipment Damage portion
of the Settlement Fund, you must provide the information requested in #8, below. You must also
submit the cost of the repairs and/or parts as well as the date(s) said repair(s) were done and/or
parts purchased. If the equipment has not been repaired, you may submit documentation
regarding the damage to the equipment and the estimated cost of such repair.
5. If you contend the equipment was damaged beyond reasonable repair, you must indicate
that in response to question 8.g. and also then respond to questions 8.h. through 8.m. You should
submit a description of the damage and the reasons you contend repairs were not reasonable,
justified or feasible.
6. If you have documentation supporting your claim and/or the amounts sought for the
repairs, parts, or specific equipment damage, you must submit it with your Claim Form. Such
documentation includes, but is not limited to, receipts, invoices, credit card statements, bank
statements, cancelled checks, equipment and/or damages parts photographs, and/or sworn
statements from you or other witnesses to the claimed damage or repair.
7. In the event there are more valid claims than funds available, repair, parts, and specific
equipment damage claims will be reimbursed pro rata based on the amount of each Qualified
Settlement Class Member’s valid claim for repairs, parts, and specific equipment damage.
8. For each piece of equipment that you contend required a repair or parts purchase or
suffered equipment loss due in whole or in part to your use of a 303 THF Product during the
Class Period, please provide the following information:
a. Identify the piece of equipment that you contend required a repair or parts or was
damaged beyond reasonable repair due in whole or in part to your use of a 303 THF Product
during the Class Period:
Equipment:__________________________________________________
Make/Model/Year:____________________________________________
b. Describe the repair(s), parts, or specific equipment damage that you claim
resulted from your use of a 303 THF Product:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________
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c. When did the repairs, parts purchase, or specific equipment damage occur?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
d. What was the cost of the repairs or parts purchase and/or value of the specific
equipment damage that occurred?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
e. For what purpose was the equipment being used when it required repairs, parts, or
sustained damage?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
f. Describe generally how you maintained the equipment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
g. Do you claim that your equipment was damaged beyond repair?
Yes:___ No:____
If your answer to question 8.g. is yes, please also respond to the following questions f.
through k, below. If your answer to question 8.g., is no, you may skip to question 9.
h. Identify the piece of equipment that you contend was damaged beyond reasonable
repair due in whole or in part to your use of a 303 THF Product during the Class Period:
Equipment:__________________________________________________
Make/Model/Year:____________________________________________
i. When was the equipment damaged beyond reasonable repair?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
j. Did you attempt to repair the equipment? Yes:___ No:____
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 7 of 9
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k. If your answer to question 8.h is yes, please describe in detail the attempted repair
and the costs of the attempted repair:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
l. If your answer to question 8.h is no, please describe in detail why you did not
attempt to repair the equipment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
m. Describe in detail why repairing the equipment was not reasonable, justifiable, or
feasible:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9. Have you received compensation for your purchase of any 303 tractor hydraulic fluid
product or for any repairs, parts, specific equipment damage or total equipment loss relating to
the alleged deceptive marking of or alleged damage caused by any 303 tractor hydraulic fluid
product?
Yes:___ No:___
10. If your answer to Question 9 was yes, please list the 303 products and/or any repairs,
parts, specific equipment damage or total equipment loss for which you were reimbursed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury the foregoing is true and correct.
Signature: ____________________ Date: ____________________
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 8 of 9
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Print Name: _____________________________
If you have any questions about this form or the Settlement, please contact the Settlement
Administrator
at:
Settlement Administrator
[INSERT SETTLEMENT MAILING ADDRESS]
[INSERT SETTLEMENT PHONE NUMBER]
[INSERT SETTLEMENT WEBSITE]
You may also contact Class Counsel at:
Thomas V. Bender
Horn Aylward & Bandy, LLC
2600 Grand Boulevard, Ste. 1100
Kansas City, MO 64108
(816) 421-0700 (phone)
(816) 421-0899 (fax)
Please do not contact Defendants, the Court, or the Court Clerk’s Office about the
Settlement.
Case 4:18-cv-00941-BP Document 135-1 Filed 03/06/20 Page 9 of 9
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EXHIBIT C-2
PART B CLAIM FORM AND INSTRUCTIONS
Hornbeck, et al. v. Orscheln Farm and Home, LLC, et al.,
Case Number 18-00941-cv-W-BP (W.D. Mo.)
Please read all of these instructions carefully before filling out your Part B Claim Form.
1. Please review the Long Form Class Notice (the “Notice”) and the Mailed Class Notice
with Purchase Data that you received when you complete your Claim Form. The Long Form
Class Notice is available on the settlement website at [WEBSITE] or by calling the Settlement
Administrator at [INSERT SETTLEMENT PHONE NUMBER].
2. Under the terms of the Settlement in this class action lawsuit, you may be entitled to
relief based on your purchase(s) of the following products during the stated Class Period:
Products Package Size Class Period
MileMaster 303 Tractor
Hydraulic Fluid
3/2 gal. January 23, 2017 to present
MileMaster 303 Tractor
Hydraulic Fluid
5 gal. May 25, 2013 to present
MileMaster 303 Tractor
Hydraulic Fluid
55 gal. May 25, 2013 to present
H-K 303 Tractor Transmission
Hydraulic Fluid
3/2 gal. May 25, 3013 to April 30, 2016
H-K 303 Tractor Transmission
Hydraulic Fluid
5 gal. May 25, 2013 to March 21, 2019
Orscheln Premium 303 Tractor
Hydraulic & Transmission
Fluid
5 gal. September 3, 2014 to August 16, 2017
SuperTech 303 Tractor
Hydraulic Oil
5 gal. February 17, 2016 to February 10,
2018
3. IF your purchases during the Class Period of the products listed above (“303 THF
Products”) are accurately set forth in the Mailed Class Notice with Purchase Data, you will
receive your Purchase Price Relief award based on those listed purchase(s) of the 303 THF
Products automatically and do not need to submit Part A of the Claim Form. Note that the
Purchase Data only reflects purchases of Orscheln Premium 303 Tractor Hydraulic &
Transmission Fluid and MileMaster 303 Tractor Hydraulic Fluid from Orscheln Farm and Home,
LLC during the time period of September 3, 2014 to August 16, 2017.
4. IF your purchases of the 303 THF Products during the Class Period are not
accurately or completely set forth in the Mailed Class Notice with Purchase Data, you may
complete and submit a Request for Correction Form. If you purchased MileMaster 303 Tractor
Hydraulic Fluid from Orscheln after August 16, 2017, those purchases are not reflected in this
Mailed Class Notice with Purchase Data, and you will need to complete and submit a Request for
Case 4:18-cv-00941-BP Document 135-2 Filed 03/06/20 Page 1 of 8
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Correction Form in order for those purchases to be considered. Also, if you purchased any of the
303 THF Products from retailers other than Orscheln Farm and Home, LLC, those purchases are
not reflected in this Mailed Class Notice with Purchase Data, and you will need to complete and
submit a Request for Correction Form in order for those purchases to be considered. The Request
for Correction Form can also be completed and submitted online at the settlement website at
[INSERT SETTLEMENT WEBSITE].
5. Under the Settlement Agreement, your purchase price reimbursement shall be based on
your 303 THF Product purchases. That award is estimated to be a $18 for each 3/2-gallon jug of
Product you purchased during the Class Period, $27 for each 5-gallon bucket, and $200 for each
55-gallon drum.
6. Under the Settlement Agreement, you also may be entitled to a Part B award for
reimbursement for the cost of any repairs, parts, and/or specific equipment damage that you
contend resulted, in whole or in part, from your use of a 303 THF Product during the relevant
Class Period. If you wish to receive this relief, you must timely complete and submit this
Part B Claim Form. You must submit this Part B Claim Form to be eligible for the cost of
any repairs, parts, and specific equipment damage relief, EVEN IF your purchases were
accurately set forth in the Mailed Class Notice with Purchase Data. Be sure to attach all
supporting documents as well as any further information you have supporting your claim for
additional funds due to alleged equipment losses, repairs and/or parts purchases. This Part B
Claim Form can also be completed and submitted online at the settlement website at [INSERT
SETTLEMENT WEBSITE].
7. You are not entitled to reimbursement under this Settlement if you were already
reimbursed for your purchases or for repairs, parts, or damage to specific equipment that you
contend was caused by your use of the above listed 303 Tractor Hydraulic Fluid Products during
the Class Period.
8. If you would like an acknowledgment of receipt of your Part B Claim Form, send it by
Certified Mail, Return Receipt Requested.
9. To submit the Part B Claim Form, you must do one of the following: (i) complete an
electronic claim form and submit it via the settlement website at [WEBSITE] on or before
[INSERT BAR DATE]; or (ii) complete a paper Claim Form and send it via fax to [INSERT
SETTLEMENT FAX NUMBER], via United States mail, postage prepaid to [INSERT
SETTLEMENT MAILING ADDRESS], or via e-mail to [INSERT SETTLEMENT E-MAIL
ADDRESS] by [INSERT BAR DATE].
10. Once your Part B Claim Form is received, the Settlement Administrator will review the
Claim Form for compliance. Your claim for monetary relief may be rejected for failure to
complete the information requested in the Claim Form or for failure to provide sufficient
supporting documentation. The Claims Administrator may contact you for additional
information.
Case 4:18-cv-00941-BP Document 135-2 Filed 03/06/20 Page 2 of 8
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11. Keep a copy of your completed Part B 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.
Case 4:18-cv-00941-BP Document 135-2 Filed 03/06/20 Page 3 of 8
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CLAIM INFORMATION – PART B
Claimant Name: Phone Number:
_____________________________________________ ________________________
Street Address: Email Address:
_____________________________________________ ________________________
City, State, Zip Code:
_____________________________________________
Complete Part B of this Claim Form only if you seek reimbursement for any repairs, parts,
and/or specific equipment damage that you contend resulted, in whole or in part, from your
use of the following products during the stated Class Period:
Products Package Size Class Period
MileMaster 303 Tractor
Hydraulic Fluid
3/2 gal. January 23, 2017 to present
MileMaster 303 Tractor
Hydraulic Fluid
5 gal. May 25, 2013 to present
MileMaster 303 Tractor
Hydraulic Fluid
55 gal. May 25, 2013 to present
H-K 303 Tractor Transmission
Hydraulic Fluid
3/2 gal. May 25, 3013 to April 30, 2016
H-K 303 Tractor Transmission
Hydraulic Fluid
5 gal. May 25, 2013 to March 21, 2019
Orscheln Premium 303 Tractor
Hydraulic & Transmission
Fluid
5 gal. September 3, 2014 to August 16, 2017
SuperTech 303 Tractor
Hydraulic Oil
5 gal. February 17, 2016 to February 10,
2018
1. Plaintiffs allege that use of the 303 Tractor Hydraulic Fluid products listed above (“the
303 THF Products”) can cause damage to tractors and other equipment in which it is used.
Defendants deny these allegations and deny that the 303 THF Products cause damage to tractors
or other equipment. As part of this Class Settlement, Class Members are entitled to submit
claims for reimbursement for repairs, parts, and specific equipment damage that the Class
Member contends resulted, in whole or in part, from use of these Products during the Class
Period.
2. The repairs, parts, and specific equipment damage may include, without limitation,
repairs, parts and equipment purchases required to remedy damage to seals, pumps, filters, gears,
clutch and brake systems, power take-off (PTO) systems and losses incurred as a result of
equipment being damaged beyond reasonable repair as a result of damage and increased or
excessive wear resulting from use of the 303 THF Products. Such increased wear and damage
Case 4:18-cv-00941-BP Document 135-2 Filed 03/06/20 Page 4 of 8
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may include, without limitation, scratching, corrosive wear, rippling, ridging, pitting, spalling
and scoring of the gears and metal components, seal damage, spiral gear damage, metal abrasion,
corrosion, surface wear, clutch wear and breakage, wet brake damage, pump failure, leakage, and
damage from deposits, sludging and thickening.
3. Consequential or other losses (such as down time) that might have been incurred as a
result of equipment being damaged are not recoverable under the Settlement Agreement. Other
examples of damage and loss not covered by this Settlement include damage caused by
negligence of the owner/operator of the equipment; damage caused by the use of a 303 THF
Product prior to the start date of the relevant Class Period; damage caused by the use of any
tractor hydraulic product not listed above; and damage caused by normal wear and tear. If the
damage to equipment resulted in part from any of these causes and in part from the 303 THF
Product’s use, then a claim would be appropriate.
4. To recover losses from this Repairs/Parts/Specific Equipment Damage portion
of the Settlement Fund, you must provide the information requested in #8, below. You must also
submit the cost of the repairs and/or parts as well as the date(s) said repair(s) were done and/or
parts purchased. If the equipment has not been repaired, you may submit documentation
regarding the damage to the equipment and the estimated cost of such repair.
5. If you contend the equipment was damaged beyond reasonable repair, you must indicate
that in response to question 8.g. and also then respond to questions 8.h. through 8.m. You should
submit a description of the damage and the reasons you contend repairs were not reasonable,
justified or feasible.
6. If you have documentation supporting your claim and/or the amounts sought for the
repairs, parts, or specific equipment damage, you must submit it with your Claim Form. Such
documentation includes, but is not limited to, receipts, invoices, credit card statements, bank
statements, cancelled checks, equipment and/or damages parts photographs, and/or sworn
statements from you or other witnesses to the claimed damage or repair.
7. In the event there are more valid claims than funds available, repair, parts, and specific
equipment damage claims will be reimbursed pro rata based on the amount of each Qualified
Settlement Class Member’s valid claim for repairs, parts, and specific equipment damage.
8. For each piece of equipment that you contend required a repair or parts purchase or
suffered equipment loss due in whole or in part to your use of a 303 THF Product during the
Class Period, please provide the following information:
a. Identify the piece of equipment that you contend required a repair or parts or was
damaged beyond reasonable repair due in whole or in part to your use of a 303 THF Product
during the Class Period:
Equipment:__________________________________________________
Make/Model/Year:____________________________________________
Case 4:18-cv-00941-BP Document 135-2 Filed 03/06/20 Page 5 of 8
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b. Describe the repair(s), parts, or specific equipment damage that you claim
resulted from your use of a 303 THF Product:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________
c. When did the repairs, parts purchase, or specific equipment damage occur?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
d. What was the cost of the repairs or parts purchase and/or value of the specific
equipment damage that occurred?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
e. For what purpose was the equipment being used when it required repairs, parts, or
sustained damage?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
f. Describe generally how you maintained the equipment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
g. Do you claim that your equipment was damaged beyond repair?
Yes:___ No:____
If your answer to question 8.g. is yes, please also respond to the following questions f.
through k, below. If your answer to question 8.g., is no, you may skip to question 9.
h. Identify the piece of equipment that you contend was damaged beyond reasonable
repair due in whole or in part to your use of a 303 THF Product during the Class Period:
Equipment:__________________________________________________
Make/Model/Year:____________________________________________
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i. When was the equipment damaged beyond reasonable repair?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
j. Did you attempt to repair the equipment? Yes:___ No:____
k. If your answer to question 8.h is yes, please describe in detail the attempted repair
and the costs of the attempted repair:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
l. If your answer to question 8.h is no, please describe in detail why you did not
attempt to repair the equipment:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
m. Describe in detail why repairing the equipment was not reasonable, justifiable, or
feasible:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9. Have you received compensation for your purchase of any 303 tractor hydraulic fluid
product or for any repairs, parts, specific equipment damage or total equipment loss relating to
the alleged deceptive marking of or alleged damage caused by any 303 tractor hydraulic fluid
product?
Yes:___ No:___
10. If your answer to Question 9 was yes, please list the 303 products and/or any repairs,
parts, specific equipment damage or total equipment loss for which you were reimbursed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Case 4:18-cv-00941-BP Document 135-2 Filed 03/06/20 Page 7 of 8
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Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury the foregoing is true and correct.
Signature: ____________________ Date: ____________________
Print Name: _____________________________
If you have any questions about this form or the Settlement, please contact the Settlement
Administrator
at:
Settlement Administrator
[INSERT SETTLEMENT MAILING ADDRESS]
[INSERT SETTLEMENT PHONE NUMBER]
[INSERT SETTLEMENT WEBSITE]
You may also contact Class Counsel at:
Thomas V. Bender
Horn Aylward & Bandy, LLC
2600 Grand Boulevard, Ste. 1100
Kansas City, MO 64108
(816) 421-0700 (phone)
(816) 421-0899 (fax)
Please do not contact Defendants, the Court, or the Court Clerk’s Office about the
Settlement.
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Case 4:18-cv-00941-BP Document 135-3 Filed 03/06/20 Page 1 of 7
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Company, Inc., Mid-States Distributing Company, Inc., and/or other retailers at any
point in time in the following package sizes during the following periods: (1) 3/2 gal.
from May 25, 2013 to April 30, 2016; (2) 5 gal. from May 25, 2013 to March 21,
2019;
o Orscheln Premium 303 Tractor Hydraulic & Transmission Fluid purchased from Orscheln Farm and Home, LLC at any point in time from September 3, 2014 to
August 16, 2017; and,
o CITGO-manufactured SuperTech 303 Tractor Hydraulic Oil in the United States from Walmart Inc. and/or other retailers at any point in time from February 17,
2016 to February 10, 2018.
• Defendants deny all of the allegations made by Plaintiffs in the lawsuit and deny that they did anything wrong. Defendants further state that the labels for these 303 Tractor Hydraulic Fluid
Products were truthful, appropriate, and adequate in all respects and that the 303 Tractor
Hydraulic Fluid Products do not cause damage to tractors or equipment. Defendants further
believe that they have, at all times, complied with applicable federal and state laws.
• If you are an eligible member of the Settlement Class, the Proposed Settlement may automatically provide you with a cash award calculated based on your purchases of the 303
Tractor Hydraulic Fluid Products during the Class Period, if Defendants have records of your
purchase history. That award is estimated to be 100% of the amount you paid for the 303
Tractor Hydraulic Fluid Products during the Class Period, based on the products’ average sales
price. If Orscheln Farm and Home, LLC had records of your purchase history, your combined
purchases of Orscheln Premium 303 Tractor Hydraulic & Transmission Fluid and MileMaster
303 Tractor Hydraulic Fluid from Orscheln during the time period of September 3, 2014 to
August 16, 2017 will be reflected in this Mailed Class Notice with Purchase Data.
How to Recover Purchase Price Relief
• If your purchase history is reflected in this Mailed Class Notice with Purchase Data and if you wish to receive only this Purchase Price Relief award, you do not have to do anything as long
as the information regarding your purchases of the 303 Tractor Hydraulic Fluid Products
during the Class Period are included with this Mailed Class Notice with Purchase Data is
accurate.
How to Revise Purchase History
• If you are an eligible member of the Settlement Class, you may complete and submit the enclosed Request for Correction Form if this Mailed Class Notice with Purchase Data has
information regarding your purchase(s) of the 303 Tractor Hydraulic Fluid Products that you
believe are wrong or incomplete. If you purchased MileMaster 303 Tractor Hydraulic Fluid
from Orscheln after August 16, 2017, those purchases are not reflected in this Mailed Class
Notice with Purchase Data, and you will need to complete and submit a Request for Correction
Form in order for those purchases to be considered. Also, if you purchased any of the 303
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THF Products from retailers other than Orscheln Farm and Home, LLC, those purchases are
not reflected in this Mailed Class Notice with Purchase Data, and you will need to complete
and submit a Request for Correction Form in order for those purchases to be considered. The
Request for Correction Form can also be completed and submitted online at the settlement
website at [INSERT SETTLEMENT WEBSITE].
How to Recover for Repairs, Parts, Specific Equipment Damage
• As part of this Class Settlement, Settlement Class Members are entitled to submit claims for reimbursement for the costs of any repairs, parts, and specific equipment damage that the
Settlement Class Member contends resulted from, in whole or in part, the use of the specified
303 Tractor Hydraulic Fluid Products during the Class Period (i.e., “Repairs/Parts/Specific
Equipment Damage”). The “Repairs/Parts/Specific Equipment Damage Claims Review
Process” is the process for reviewing and paying claims made by Settlement Class Members
for the additional repairs, parts, and specific equipment damage the Settlement Class Member
contends resulted from, in whole or in part, the use of the 303 Tractor Hydraulic Fluid Products
during the Class Period and is available at [WEBSITE].
• Such losses may include, without limitation, repairs, parts and equipment purchases required to remedy damage to seals, pumps, filters, gears, clutch and brake systems, power take-off
(PTO) and losses incurred as a result of equipment being damages beyond reasonable repair as
a result of damage and increased or excessive wear. Such increased wear and damage may
include, without limitation, scratching, corrosive wear, rippling, ridging, pitting, spalling and
scoring of the gears and metal components, seal damage, spiral gear damage, metal abrasion,
corrosion, surface wear, clutch wear and breakage, wet brake damage, pump failure, leakage,
and damage from deposits, sludging and thickening.
• Consequential or other losses (such as down time) that might have been incurred as a result of equipment being damaged are not recoverable under this Settlement Agreement. Other
examples of damage and loss not covered by the Proposed Settlement include damage caused
by negligence of the owner/operator of the equipment; damage caused by the use of a Product
prior to the start date of the Class Period; damage caused by the use of any 303 product not
listed above; damage caused by normal wear and tear; and damages or losses of any kind other
than the damage to or loss of a specific piece of equipment. If the damage to equipment
resulted in part from any of these causes and in part from the 303 THF Product’s use, then that
damage is recoverable.
• To be eligible to recover for repairs, parts, and specific equipment damage, you must provide the information requested on the enclosed Part B Claim Form, which includes narrative
information describing the equipment malfunction, repairs and/or parts purchases as necessary
to fully describe what occurred and what repair/parts or other actions were required for your
equipment. You must also submit the cost of the repairs and/or parts as well as the date said
repairs were done and/or parts purchased. If you have documentation supporting your claim
and/or the amounts sought for repairs, parts, or specific equipment damage, you must submit
it with your Claim Form. The Part B Claim Form can also be completed and submitted online
at the settlement website at [INSERT SETTLEMENT WEBSITE].
Case 4:18-cv-00941-BP Document 135-3 Filed 03/06/20 Page 3 of 7
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• If the equipment was damaged beyond reasonable repair or has not been repaired, you must indicate that in response to Question 8.g. on the Part B Claim Form and also then respond to
Questions 8.h. through 8.m. You should submit a description of the damage and the reasons
you contend repairs were not reasonable, justified or feasible.
You are not entitled to reimbursement under this Settlement if you were already reimbursed for
your purchases or for repairs, parts, or damage to specific equipment that you contend was
caused by your use of the above listed 303 Tractor Hydraulic Fluid Products during the Class
Period.
YOUR RIGHTS AND CHOICES IF YOU ARE A MEMBER OF THE CLASS:
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Hornbeck, et al. v. Orscheln Farm and Home, LLC, et al.
Case Number 18-00941-cv-W-BP (W.D. Mo.)
SETTLEMENT CLASS MEMBER PURCHASE DATA DURING THE CLASS PERIOD
THE 303 TRACTOR HYDRAULIC FLUID PRODUCT PURCHASE INFORMATION FOR
___________________ DURING THE CLASS PERIOD IS AS FOLLOWS:
Total 5-gallon THF Product Purchased: _____ Distribution Amount: $________
▪ (This includes purchases of Orscheln Premium 303 and MileMaster 303from Orscheln Farm and Home, LLC during the time period of
September 3, 2014 to August 16, 2017.)
TOTAL DISTRIBUTION AMOUNT TO BE PAID: $____________
If you believe this information does not accurately set forth your purchases of the specified 303
THF Products during the Class Period, you may timely complete and submit the enclosed Request
for Correction Form, which is also available for completion at the settlement website at
________________.
If you purchased MileMaster 303 Tractor Hydraulic Fluid from Orscheln after August 16, 2017,
those purchases are not reflected in this Mailed Class Notice with Purchase Data, and you will
need to complete and submit a Request for Correction Form in order for those purchases to be
considered. Also, if you purchased any of the 303 THF Products from retailers other than Orscheln
Farm and Home, LLC, those purchases are not reflected in this Mailed Class Notice with Purchase
Data, and you will need to complete and submit a Request for Correction Form in order for those
purchases to be considered.
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