Form Ca5163 – Fill Out and Use This PDF

YOU mUST SUBmIT YOUr

ClaIm fOrm BY JUlY 23, 2013

ClaIm fOrm

IT IS ImPOrTaNT THaT YOU TrY TO aNSWEr all QUESTIONS aND aS fUllY aND aCCUraTElY aS POSSIBlE. faIlUrE TO fUllY aNSWEr THE QUESTIONS Or TO PrOVIDE THE rEQUESTED INfOrmaTION aND/Or DOCUmENTaTION maY ImPaCT YOUr aBIlITY TO OBTaIN BENEfITS.

I.By submitting this Claim form, I state that I currently own, or previously owned, a structure that contains or contained one or more Pella Proline brand casement, awning and/or transom window(s) manufactured by Pella between January 1, 1991 and December 31, 2006 (collectively “Pella Proline Casement Window(s)”).

II.Identiication of Person Submitting this Form.

First Name

MI

Last Name

Mailing Address, including apartment, unit or box number

City

State

Zip Code

III.Claim Information.

If you need additional space to complete this form, please attached additional pages, and clearly identify by ques- tion number which question(s) you are answering on your attached pages.

1.Please identify the address of the building which contains or contained one or more Pella ProLine Casement Window(s) for which this claim applies, if different from the above:

Mailing Address, including apartment, unit or box number

b. Number of units, if not a single family home:

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2. Identify the number of Pella ProLine Casement Window(s) installed.

Please attach whatever documentation you have establishing the number of Pella ProLine Casement Window(s) that are/were installed. Pella’s name may appear on the knob of the window crank.

The following questions seek information and documentation establishing that you meet the requirements to receive beneits under the Settlement. You will need to produce documentation suficient to establish these items in order to receive beneits under the Settlement.

3.If known, please identify the purchase date of your Pella ProLine Casement Window(s) identiied above and from whom the windows were purchased. Include all purchase order numbers, if known.

b.From whom the windows were purchased (Individual or Business)

c.Purchase order numbers (if known)

Purchase Order 1

Purchase Order 2

Purchase Order 3

If known, please identify the date of installation of your Pella ProLine Casement Window(s) identiied above. If not known, please identify the date your home was built.

4.If available, please provide the glass etch information for each window. This information is located on the glass in one of the corners of each window.

Note: For examples of glass etch information placement please reference figure 1 of the instructions page.

Glass Etch 1

Glass Etch 2

Glass Etch 3

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5.If available, please provide the Product Identity Stamps for window(s) manufactured from 1991 through 1997, and please provide the Unit ID labels for window(s) manufactured from 1997 through 2006.

a.The Product Identity Stamp is located on the sill of the product. To ind it, open the sash and examine the frame sill assembly. Examine the area around the pivot head screw or the lat part where the hardware is attached and slides. When looking for the stamp, it may be necessary to clean built up dirt from the sill to be able to see the stamp. The stamp is located approximately 2 to 4 inches from one corner of the unit.

Note: For an example of Product Identity Stamp placement please reference figure 2 of the instructions page.

Product Identity Stamp 1

Product Identity Stamp 2

Product Identity Stamp 3

b.The Unit ID label was adhered to the glass of each window. The Label is a string of number that could be 50+ digits long. To ind it, examine the interior glass on spacer and the lower corner of the glass.

Note: For an example of Unit ID label placement please reference figure 3 of the instructions page.

Unit ID 1

Unit ID 2

Unit ID 3

Please attach any documentation and/or photographs to show the purchase date or date of installation of your Pella ProLine Casement Window(s), or to show when your home was built. Include any receipts or purchase orders.

You may have documents from the original purchase, documents from Pella identifying the type and vintage (year of manufacture) of the window(s), or other invoices, photographs, or documents with identifying infor- mation. This documentation needs to be provided.

6. Identify whether the wood portion of the Pella ProLine Casement Window(s) that faces the interior of the building

was “inished,” i.e., painted, stained, or varnished.		No		Yes

a.If the wood portion of the Pella ProLine Casement Window(s) was inished, please identify, if you know, whether the window was sold already inished or whether it was inished after sale or installation by someone other than Pella (e.g., the homeowner, the owner of the building, a contractor or a painter, etc.).

Please attach any documentation and/or photographs you may have to show whether or not the portion of the Pella

ProLine Casement Window(s) that faces the interior of the building was “inished”.

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7. Identify whether your Pella ProLine Casement Window(s) has/have sustained water-intrusion related damage, such

as wood rot.

No

Yes

If you replied Yes to question 8 above, please answer the following questions:

8. Identify the nature of the damage alleged in the claim you are making as part of this Class Action litigation.

a. Please specify whether you are making a claim for (check all that apply):

Damage to your window(s) that has/have already been repaired or replaced

Damage to your window(s) that has/have NOT already been repaired or replaced

Damage to your window inish(es) that has/have already been repaired or replaced

Damage to your window inish(es) that has/have NOT already been repaired or replaced

The cost of installing a replacement window(s) that has/have already been replaced

Damage to other property other than your window(s) (such as damage to the structure surrounding the window(s)) caused by water intrusion in the window that has/have already been repaired or replaced

Damage to other property other than your window(s) (such as damage to the structure surrounding the window(s)) caused by water intrusion in the window that has/have NOT already been repaired or replaced

b. Identify the Location of any property damage in addition to your window(s) (check all that apply):

c. State the total number of Pella ProLine Casement Window(s) damaged by water intrusion:

Because the Settlement Administrator must verify that your window(s) experienced damage covered by the Settlement, please attach any photographs or other documentation to verify the damages claimed above.

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9.Have you at any time prior to November 1, 2012 notiied Pella Corporation, Pella Windows and Doors, Inc.

(collectively “Pella”), any employee of Pella Corporation, or a Pella Sales branch regarding wood rot or water

intrusion related to your Pella ProLine Casement Window(s) identiied in this Claim Form?	No	Yes
If “Yes”, state:

Name (Business or Individual) to whom you made the notiication

If you have any contemporaneous documentation (documentation made or received at or near the time of the

notiication) that veriies any such notiications, please attach that documentation. Examples of such documen-

tation would be a copy of a letter or email received from Pella Customer Service.

10.Have you at any time prior to November 1, 2012 made a claim or claims to Pella Corporation or Pella Windows and

Doors, Inc. (collectively “Pella”), any employee of Pella Corporation, or a Pella Sales branch for repair or replacement

damage to your Pella ProLine Casement Window(s) identiied in this Claim Form, which you alleged was incurred

by the failure of your Pella ProLine Casement Window(s)?

No

Yes

If “Yes”, state (1) the date of the claim, (2) to whom you made the claim, (3) the nature of the alleged damage:

MM DD YYYY

Name to whom you made the claim (Individual or Business)

The nature of the alleged damage:

If you have any contemporaneous documentation (documentation made or received at or near the time of the claim)

that veriies any such claims, please attach that documentation. Examples of such documentation would be a copy

of a letter or email received from Pella Customer Service.

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If you have any contemporaneous documentation (documentation made or received at or near the time of the claim)

that veriies any such denial of claims, please attach that documentation. Examples of such documentation would be a copy of a letter or email received from Pella Customer Service.

12.Did Pella, any employee of Pella Corporation, or a Pella Sales branch inspect the Pella ProLine Casement Window(s)

(or the surrounding property) identiied in this Claim Form, after you discovered the damages alleged in this Claim

Form?

No

Yes

If “Yes”, state who performed the inspection, and the date of the inspection:

Date of the inspection

MM DD YYYY

Name of who performed the inspection (Individual or Business)

If you have any contemporaneous documentation (documentation made or received at or near the time of the claim)

that veriies such an inspection, please attach that documentation. Examples of such documentation would be a copy of a letter or email received from Pella Customer Service.

13. Have you previously repaired any alleged damage to or from the Pella ProLine Casement Window(s) or replaced

such Window(s)?

No

Yes

If “Yes”, state the date of the repair or replacement, and the nature of the repair or replacement:

Date of the repair or replacement

MM DD YYYY

Nature of the repair or replacement:

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Please attach contemporaneous documentation (documentation made or received at or near the time of the repair or replacement) that veriies the date and nature of the repair or replacement and the amount of your repair or replacement costs. Examples of such documentation include receipts, invoices, canceled checks, or other inancial

records showing the amount of money paid for the repair or replacement and the nature of the repair or replace- ment performed.

15.If you have not had the alleged damage repaired, how much will it cost you to repair the alleged damage to property other than your window(s) caused by water intrusion in your Pella ProLine Casement Window(s)?

Please attach documentation that veriies the nature of the damage and the costs necessary to repair the damage

to property other than your window(s), including costs for labor, paint, wallboard, or other materials necessary to

repair. Examples of such documentation include a qualiied contractor’s written estimate with line item estimates

for each type of cost.

16. Identify whether you have made any claims on your homeowners insurance for water intrusion damage to your

Pella ProLine Casement Window(s) or resulting property damage

No

Yes

If “Yes”, state:

a. With whom you have your homeowners insurance (Individual or Business)

Please attach documentation showing any such claims, any documentation you submitted in support of any such claims, and the result of any such claims.

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17.Identify whether you have made any claims to anyone else (such as a contractor, subcontractor, siding manufac- turer, etc.) for water intrusion damage to your Pella ProLine Casement Window(s) or resulting property damage.

b.To whom the claim was made (Individual or Business)

c.The nature of the claim:

Please attach documentation showing any such claims, any documentation you submitted in support of any such claims, and the result of any such claims.

18. Identify whether you have ever initiated a lawsuit or other legal claims (whether it is resolved or not resolved)

against Pella Corporation or Pella Windows and Doors, Inc.?

No

Yes

If “Yes”, state:

a. The nature of the lawsuit or other legal claim:

b. The location of the lawsuit or other legal claim:

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d.The lawyer representing you in that lawsuit or other legal claim.

Name

Mailing Address, including apartment, unit or box number

City

State

Zip Code

IV. Settlements.

1.Have you entered into any oral or written Settlement for the damage alleged in this Claim Form with Pella Corpo- ration, Pella Windows and Doors, Inc., or received the beneit of any payments to you or on your behalf as a result

of those damage allegations?

No

Yes

2.Have you entered into any oral or written settlement for the damage alleged in this Claim Form with anyone

other than Pella Corporation, Pella Windows and Doors, Inc. (such as a contractor, a siding manufacturer, etc.), or received the beneit of any payments to you or on your behalf as a result of those damage allegations?

If “Yes”, provide the following information:

a.

With whom you made the Settlement (Individual or Business)

b.

Date of Settlement or payment:

–

–

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V.Ownership Documentation.

1.Please attach documentation that veriies that you are the current or former owner of the property containing the Pella ProLine Casement Window(s) identiied above, during the period when the Pella ProLine Casement

Window(s) were/need to be repaired or replaced.

Examples of suficient documentation of property ownership include a copy of property tax bills, a copy of property deeds or deeds of trust, a copy of a declaration page from a policy of title or homeowners insurance, a copy of mortgage statement, a copy of mortgage payment coupon, or other documentation demonstrating ownership, including the property address. The documentation must be (a) for/from the year in which the repairs or replacements took place, or (b) for/from the current year if the window(s) has/have yet to be repaired or replaced.

If you are the owner of an individual living unit such as a condominium or townhouse, then you must also provide satisfactory proof that you have/had the maintenance obligation during the period when the Pella ProLine Casement Window(s) were/need to be repaired or replaced, for the damage alleged in your Claim Form.

Example of satisfactory proof would be a copy of the Covenants, Conditions and restrictions governing the condominium or townhouse.

VI. additional Information:

1. Please state below any additional information which you believe would be helpful in evaluating your claim.

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VII. By the iling of this Claim Form, you hereby submit to the jurisdiction of the United States

District Court for the Northern District of Illinois for the purposes of this claim.

VIII. The beneits provided by the Settlement are for otherwise unreimbursed costs and expenses incurred by you related to damage covered by the settlement. By submitting this Claim Form, you verify that other than what you disclosed in this Claim Form, you have not otherwise been reimbursed or com- pensated for the costs and expenses you are seeking in this Claim Form.

IX. The beneits provided by the Settlement DO NOT cover damage that was caused by any of the fol-

lowing causes:

(i) misuse, or intentional, reckless, accidental, and/ or negligent physical damage to a window caused directly

or indirectly by a Settlement Class Member or other person; (ii) damage to window(s) to the extent resulting from natural disaster including, but not limited to ire, hurricane, wind, lood, earthquake or earth movement;

(iii)damage resulting from causes unrelated to window performance (such as plumbing leaks, interior water spills, ire damage, caulk or putty cracks, or any other defect in the structure); (iv) damage due to racking,

covering or blocking of weep holes or drilling holes through the window frame; (v) damage due to improper storage, handling, installation, modiication, or maintenance; (vi) damage due to an altered or reinstalled win- dow; (vii) damage due to inishes, sealants or caulking not applied by Defendants or failure to inish the product in a timely manner; (viii) damage caused to wood, medium density iberboard, or sheetrock, sills or jambs by

natural weathering; (ix) damage caused by exterior leaks; and (x) damage caused by interior condensation.

By submitting this Claim Form, you verify, under oath and the penalty of perjury, that all of the damage for which you are seeking beneits in this Claim Form was not caused by any of the causes identiied in this section.

X.Certiication, Under the Penalty of Perjury and Notarization

Pursuant to 28 U.S.C Section 1746, I declare under penalty of perjury that the answers and statements made in the form

are true and correct and all enclosures are true and correct copies; and:

1.The Social Security Number or Taxpayer Identiication Number for this claimant is correct; and

2.The claimant is NOT subject to backup withholding because: (a) the claimant is exempt from backup withhold- ing, or (b) the claimant has not been notiied by the Internal Revenue Service (IRS) that the claimant is subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notiied the claimant that he or she is no longer subject to the backup withholding; and

3.The claimant is a U.S. citizen or other U.S. person.

Note: You must cross out item 2 above if you have been notiied by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return.

The Internal revenue Service does not require your consent to any provision of this document other than certiications required to avoid backup withholding.

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By signing this Claim Form, I certify under the penalty of perjury, that the information I provided in this Claim Form is true and correct, to the best of my knowledge.

Subscribed and sworn to before me this

day of

, 20

Signature of Claimant

Notary Public

Date of Signature

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