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ToCF#1026
❏ I have chosen the rebate certificate remedy and have not selected any of the other remedies
listed on this Claim Form.
❏ I declare under penalty of perjury that the Toshiba DVD Player At Issue experienced one or
more Playback Incompatibilities on or before October 15, 2004.
If you experienced a Playback Incompatibility with the Toshiba DVD Player at Issue and you replaced
the Toshiba DVD Player at Issue on or before October 15, 2004 and after the date of the purchase of
the Toshiba DVD Player At Issue with a DVD player made by another manufacturer that you
specifically purchased as a result of the Playback Incompatibility, you will receive a Rebate Certificate
if you provide all of the required information and documentation. Specifically, you must: (1) provide
documentation of your original purchase or receipt of the Toshiba DVD Player, and (2) provide proof
of purchase of a replacement DVD player, dated before the date of the Settlement Agreement and
after the date of the purchase of the Toshiba DVD player, and (3) declare under penalty of perjury
that the exclusive and direct cause of your purchase of a non-Toshiba DVD player was the actual
manifestation of one or more Playback Incompatibilities.
(1) PROOF OF PURCHASE OR RECEIPT OF TOSHIBA DVD PLAYER AT ISSUE
TO SHOW THAT I PURCHASED OR ACQUIRED A TOSHIBA DVD PLAYER ON OR
BEFORE DECEMBER 31, 2001, I AM ATTACHING THE FOLLOWING DOCUMENTS
(check all that apply):
_____ A legible copy of the original and contemporaneously dated purchase receipt which
identifies the purchase of a Toshiba DVD player from a retail seller;
_____ An invoice marked “paid” which identifies the retail seller, the seller's address and
the purchase of a Toshiba DVD player;
_____ A canceled check contemporaneously identifying the purchase of a Toshiba DVD
player;
_____ A credit card bill which identifies the purchase of a Toshiba DVD player.
(2) PROOF OF PURCHASE OF A REPLACEMENT DVD PLAYER
TO SHOW THAT I PURCHASED A REPLACEMENT DVD PLAYER FROM ANOTHER
MANUFACTURER ON OR BEFORE OCTOBER 15, 2004 AND AFTER THE DATE OF THE
PURCHASE OF A TOSHIBA DVD PLAYER, I AM ATTACHING THE FOLLOWING
DOCUMENTS (check all that apply):
_____ A legible copy of the original and contemporaneously dated purchase receipt which
identifies the purchase of another DVD player from a retail seller;
_____ An invoice marked “paid” which identifies the retail seller, the seller's address and
the purchase of another DVD player;
_____ A canceled check contemporaneously identifying the purchase of another DVD
player;
_____ A credit card bill which identifies the purchase of another DVD player.