ClaimFormNoClaimantID*Name* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email II. Please Provide ProofYou must provide proof in either one of the following two ways: . (1) an original or copy of your customer receipt, OR (2) an original or copy of your credit or debit card statementPlease choose one option below* OPTION (1): You may attach an original or a copy of your customer receipt that contains more than the last 5 digits and/or expiration date of your credit or debit card and shows that you made a transaction at any Fastenal store in the United States at any time during the period August 22, 2016 to September 6, 2018. By completing this Claim Form you also confirm that you used your own personal card for the Fastenal transaction. OPTION (2): You may attach an original or a copy of your credit or debit card statement showing that you made a transaction at any Fastenal store in the United States at any time during the period August 22, 2016 to September 6, 2018. By completing this Claim Form you also confirm that you used your own personal card for the Fastenal transaction. Before providing your statement or copy of your statement, please redact (meaning you may white-out or mark-over) information contained in your credit or debit card statement to prevent it from showing things like your account numbers, your other purchases, etc. The only information that is required to show on your statement for purposes of making a claim under this Settlement is your name, address, and all of the details of your transaction from any Fastenal store in the United States, including the date and amount of your purchase. ATTACH PROOF* Drop files here or Accepted file types: pdf, jpg, jpeg. IMPORTANT: You may make only one claim regardless of whether you have made one or more than one eligible credit or debit card transaction. Accordingly, if you had more than one eligible transaction you only need to provide proof of either one receipt or one statement showing that you made one credit or debit card transaction at any Fastenal store in the United States at any time during the period August 22, 2016 to September 6, 2018. III. Please Sign This FormSignature Line* I declare that the facts stated in this Claim Form are true and accurate. CAPTCHAUnique IDPhoneThis field is for validation purposes and should be left unchanged.
