*PEKAWONE*
Eubank v. Pella Corporation Settlement Administrator
P.O. Box 404041
Louisville, KY 40233-4041
PEK
FOR CLAIMS
PROCESSING
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REV
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Eubank, et al. v. Pella Corporation, et al.
U.S. DISTRICT COURT
NORTHERN DISTRICT OF ILLINOIS
Case No. 06-cv-4481
Submitting a Claim under the Eubank v. Pella Corp. Settlement Agreement
YOU MUST SUBMIT
YOUR CLAIM FORM
POSTMARKED BY
JUNE 20, 2018
To make a claim through the claims process for benets that may be available as a result of the settlement reached in the
litigation titled Eubank et al. v. Pella Corporation et al., you must ll out the attached Claim Form as completely as you
can and send it to the following address so that it is postmarked by June 20, 2018:
Eubank v. Pella Corporation Settlement Administrator
P.O. Box 404041
Louisville, KY 40233-4041
Each property owner making a claim must submit a separate Claim Form. You may obtain extra copies by calling
1-866-658-6764 or online at the following address: www.pellawindowsettlement.com.
Class members submitting claims may be contacted by representatives of counsel for the class or by the settlement
administrator for additional information regarding the class members claims.
Deadline: If you do not complete and mail your Claim Form to the Eubank v. Pella Corporation Settlement Administrator
at the address provided above so that it is postmarked by June 20, 2018, your claim will be rejected and you will be
precluded from sharing in any benets provided by the settlement. Do not send your Claim Form to the Court or to
anyone other than the Eubank v. Pella Corporation Settlement Administrator.
IT IS IMPORTANT THAT YOU TRY TO ANSWER ALL QUESTIONS 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.
If you need additional space to complete the Claim Form, please attach additional pages, and identify by question
number which question(s) you are answering on your attached pages.
First Name M.I. Last Name
Primary Address
Primary Address Continued
City State Zip Code
Foreign Province Foreign Postal Code Foreign Country Name/Abbreviation
CLAIMANT INFORMATION
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*PEKAWTWO*
CLAIM FORM
NOTE: SUPPORTING DOCUMENTATION WILL BE REQUIRED FOR ALL CLAIMS. A LIST OF
ACCEPTED SUPPORTING DOCUMENTATION CAN BE FOUND ON PAGES 9-10 OF THE FORM.
A. IDENTIFICATION OF PERSON SUBMITTING THIS FORM AND THE STRUCTURE CONTAINING
PELLA WINDOWS.
1. Your phone number and email:*
Daytime Telephone Number Evening Telephone Number
Email
Secondary Email
* For promptness and accuracy, we prefer to contact you by email and will do so if possible. Accordingly,
please provide your email address. If necessary, we may also contact you by phone or by US mail.
2. Physical Address of Structure:
If different from the above mailing address, please identify the street address of the Structure which contains
or contained one or more Pella ProLine Casement window(s) for which this claim applies:
Street Address, including apartment, unit or box number
City State Zip Code
3. With respect to the Structure, please check all that apply:
You are the current owner
You are the former owner
You are the original owner
4. How many Pella ProLine Casement, Awning and Transom windows are/were installed in the Structure?
Total number of windows:
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*PEKAWTHREE*
B. IDENTIFICATION OF ELIGIBLE DAMAGE AND COSTS.
The settlement provides benets to certain claimants who can establish “Eligible Damage.” A copy of the settlement
agreement may be found at www.pellawindowsettlement.com. Please ll out the information below to identify what
Eligible Damage and costs you are claiming. For purposes of the settlement, Eligible Damage means water-related
damage to a Pella ProLine® brand wood casement, awning, and/or transom window (including 250 and 450 Series)
manufactured by Pella Corporation between January 1, 1991 and December 31, 2009 (“Window”) because of water
penetrating between the aluminum cladding of the window and the window sash, as well as the consequences of
such water penetration and damage, which includes: 1. Damage to the Window; 2. Damage to the nishing on such
Window; 3. Damage to other property surrounding such Window, such as water related damage to the Structure in
which such Window was installed; and 4. Labor costs necessary to replace a window or its sash because it was or is
damaged from water penetration as described above and/or was or is causing damage to other property surrounding
the Window such that replacement was or is necessary to x such damage.
For Eligible Damage to or from a Window repaired or replaced more than 15 years after the Date of Sale, or if not
repaired, with a Date of Sale that is more than 15 years before the Direct Class Notice Date, the cash award will be
25% of the sum of these four categories.
1. HowmanyoftheWindowsidentiedinsectionA.4abovedoyoucontendsustainedEligibleDamage
and already were repaired or replaced or still need to be repaired or replaced?
a. Windows With Eligible Damage that already were repaired/replaced:
b. Windows With Eligible Damage that still need to be repaired/replaced:
_________
Total Windows With Eligible Damage:
2. Categories and Costs of Eligible Damage. Please identify the type of Eligible Damage that you sustained and
the total to repair such Eligible Damage. To the extent reasonably possible, please separate Eligible Damage and
costs into the following four categories:
a. Cost of Product. If you already replaced or need to replace one or more windows or sashes because of Eligible
Damage, then check the “Cost of Product” category, and state the total amount paid or to be paid to replace such
product. Please include only the cost of the actual product in this category, not other costs such as the cost to
install or nish the product.
b. Cost of Finishing. If you incurred or need to incur costs to repair damage to nishing on one or more windows
or sashes because of Eligible Damage, then check the “Cost of Finishing” category, and state the total amount paid
or to be paid to nish or renish the windows or sashes (including cost of paint, stain or varnish and/or the cost of
labor to have a contractor apply the paint, stain or varnish). “Finishing” refers to painting, staining or varnishing
the exposed wood portion of a window or sash. It does not include painting, staining or varnishing wood trim,
wallboard or other surfaces that are not on the window but are surrounding a window, which belong in the
“Cost to Repair Other Property” category.
c. Cost of Installation. If you incurred or need to incur labor costs to install one or more windows or sashes
that were damaged because of Eligible Damage, then check the “Cost of Installation” category, and state the total
amount paid or to be paid to install such windows or sashes.
d. Cost to Repair Other Property. If you incurred or need to incur costs to repair other categories of damage such
as damage to surrounding structure, trim, wallboard, or paint because of water penetrating between the aluminum
cladding of the window and the window sash, then check the “Costs to Repair Other Property” category, and state
the total amount paid or to be paid to repair such other damage (including labor costs and costs of materials such
as paint, wallboard, spackle, etc.).
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*PEKAWFOUR*
NOTE: To the extent that you cannot separate the Eligible Damage into the categories described above
(for instance, if the repairs and estimates have already occurred and are not separated out into these categories),
please provide as much information about the Eligible Damage as possible.
C. SUMMARY OF ELIGIBLE DAMAGE AND COSTS CLAIMED FOR ALL WINDOWS IDENTIFIED IN
RESPONSE TO QUESTION B.1.
1. Windows That Already Were Repaired/Replaced
For the windows and/or sashes that you already repaired or replaced and identied in response to Question B.1.a.,
above, please identify below the type of Eligible Damage that was repaired or replaced and the total amount
incurred to repair or replace such Eligible Damage:
Check all categories
of Eligible Damage Costs
*
Cost of Product: $
.
Cost of Finishing: $
.
Cost of Installation: $
.
Cost to Repair Other Property: $
.
(i.e., damage in addition to __________________________
those items listed above)
Total Costs for All Repaired Windows
$
.
* Important: If you do not know the precise breakdown of costs, please try to obtain this information from your
contractor. If this information is unavailable, please check all categories of Eligible Damage that
were repaired and put the total repair amount in “Total Repair Costs for All Repaired Windows.”
2. Windows That Still Need To Be Repaired/Replaced
For the windows and/or sashes that still need to be repaired or replaced and were identied in response to Question
B.1.b., above, please identify below the type of Eligible Damage that needs to be repaired or replaced and the total
amount needed to repair such Eligible Damage:
Check all categories
of Eligible Damage Costs
**
Cost of Product: $
.
Cost of Finishing: $
.
Cost of Installation: $
.
Cost to Repair Other Property: $
.
(i.e., damage in addition to __________________________
those items listed above)
Total Repair Costs for All Windows
$
.
to be Repaired or Replaced
** Important: Please attach the estimate from Pella and/or window contractor. If you have yet to obtain an
estimate from Pella or another window contractor, please instruct the contractor, to the extent
practicable, to separate the estimate into the above categories of Eligible Damage.
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*PEKAWFIVE*
D. INFORMATION ON EACH WINDOW THAT SUSTAINED OR CAUSED ELIGIBLE DAMAGE.
For each Window with Eligible Damage, please ll out the information below, identifying (1) the type of window
(Casement, Awning or Transom); (2) the Glass Etch and Product ID Stamp or Unit ID Label; (3) the date when
Eligible Damage to the window or surrounding area was discovered; (4) whether the Eligible Damage already has
been repaired and, if so, the date of repair; and (5) the type of Eligible Damage sustained to or from that window
and the costs of repairing such damage.
Glass Etch. The Glass Etch is located in one of the corners of each window, and will look something like one of
the two following examples:
Product ID Stamp. Windows manufactured between 1991 - 1997 have a Product ID Stamp that is typically located
near the corner of the sill of the product, and looks like this:
Unit ID Label. Windows manufactured between 1998 - 2009 have a Unit ID Label that can be found on interior
lower corner of the glass of each window, and looks like this:
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*PEKAWSIX*
1. WINDOW #1
a. Window Type: Casement Awning Transom
b.
Glass Etch Number:
and
Product ID Stamp (1991 - 1997 windows) or Unit ID Label (1998 - 2009):
c. Date when Eligible Damage was rst noticed (mm/dd/yyyy):
d. Was Eligible Damage Previously Repaired? Yes No
If “Yes,” date (mm/dd/yyyy):
e. Is/Was Eligible Damage to the full window unit or just to the sash? full unit sash only
f.
Type of Eligible Damage sustained and cost to repair such damage:
Check all categories
of Eligible Damage Costs
**
Cost of Product: $
.
Cost of Finishing: $
.
Cost of Installation: $
.
Cost to Repair Other Property: $
.
(i.e., damage in addition to __________________________
those items listed above)
Total Repair Costs for this window/sash:
$
.
** Important: Please attach the estimate from Pella and/or window contractor. If you have yet to obtain an
estimate from Pella or another window contractor, please instruct the contractor, to the extent
practicable, to separate the estimate into the above categories of Eligible Damage.
g.
If you already replaced this window/sash, was replacement necessary to remediate
water damage to property surrounding the window and to prevent further such damage? Yes No
h.
If you still need to replace this window/sash, is replacement necessary to remediate
water damage to property surrounding the window and to prevent further such damage? Yes No
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*PEKAWSEVEN*
2. WINDOW #2 *
a. Window Type: Casement Awning Transom
b.
Glass Etch Number:
and
Product ID Stamp (1991 - 1997 windows) or Unit ID Label (1998 - 2009):
c. Date when Eligible Damage was rst noticed (mm/dd/yyyy):
d. Was Eligible Damage Previously Repaired? Yes No
If “Yes,” date (mm/dd/yyyy):
e. Is/Was Eligible Damage to the full window unit or just to the sash? full unit sash only
f.
Type of Eligible Damage sustained and cost to repair such damage:
Check all categories
of Eligible Damage Costs
**
Cost of Product: $
.
Cost of Finishing: $
.
Cost of Installation: $
.
Cost to Repair Other Property: $
.
(i.e., damage in addition to __________________________
those items listed above)
Total Repair Costs for this window/sash:
$
.
** Important: Please attach the estimate from Pella and/or window contractor. If you have yet to obtain an
estimate from Pella or another window contractor, please instruct the contractor, to the extent
practicable, to separate the estimate into the above categories of Eligible Damage.
g.
If you already replaced this window/sash, was replacement necessary to remediate
water damage to property surrounding the window and to prevent further such damage? Yes No
h.
If you still need to replace this window/sash, is replacement necessary to remediate
water damage to property surrounding the window and to prevent further such damage? Yes No
* IF YOU HAVE MORE THAN TWO WINDOWS WITH ELIGIBLE DAMAGE,
USE THE ATTACHED “ADDITIONAL WINDOW FORM”
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*PEKAWEIGHT*
3. Date(s) of Purchase
Were all Windows with Eligible Damage purchased on the same date? Yes No
If “Yes,” state the date (mm/dd/yyyy):
If “No,” identify the various purchase dates and the Windows purchased on those dates:
- date of purchase for window #s ______________________
- date of purchase for window #s ______________________
4. Date(s) of Installation
Were all Windows with Eligible Damage installed on or around the same date? Yes No
If “No,” identify the various installation dates and the Windows installed on those dates:
- date of installation for window #s _____________________
- date of installation for window #s _____________________
5. Additional Information
Please state below any additional information which you believe would be helpful in evaluating your claim.
9
*PEKAWNINE*
E. REQUIRED SUPPORTING DOCUMENTS
1. Ownership Documentation. Please attach documentation that veries that you are the current or former owner of
the property containing the Pella ProLine Casement, Transom or Awning Window(s) identied in your Claim Form
during the period when Eligible Damage was repaired or needs to be repaired.
Examples of sufcient documentation of property ownership include a copy of a mortgage statement or
payment coupon, the declarations page of property, homeowners or title insurance, a copy of a property tax bill,
property deeds or deeds of trust, 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. YOU NEED ONLY PROVIDE ONE
FORM OF DOCUMENTATION.
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,
Awning or Transom
Window(s)’ Eligible Damage was repaired or needs to be repaired. Examples of satisfactory
proof of maintenance obligations include a copy of the Covenants, Conditions and restrictions governing the
condominium or townhouse.
2. Documentation that 1991-2009 ProLine Casement, Awning or Transom windows were installed in your
Structure. This settlement only covers Eligible Damage caused to or by ProLine Casement, Awning or Transom
Windows manufactured between 1991 and 2009 that were installed in your Structure. It is therefore necessary to
establish that the Windows identied in Sections B and C, above, are covered by the settlement.
Establishing qualifying windows. As shown above, you can establish that you have qualifying windows by
identifying the Glass Etch and Product ID Stamp or Unit Label of any window for which you are seeking benets under
this settlement. This can be done by providing that information in writing or by providing a photograph of the Glass Etch
and Product ID Stamp or Unit Label of each window for which you are submitting a claim. If you are unable to identify the
Glass Etch and Product ID Stamp or Unit Label of any window for which you are submitting a claim, then you must submit
documentation establishing that each such window is of the type and vintage covered by the settlement. This may be
established, for example, by submitting (1) a signed statement from your contractor on the contra ctor s letterhead
or in an afdavit identifying your windows as ProLine Casement, Awning or Transom windows manufactured
between 1991-2009; (2) a prior written statement from Pella or any Pella distributor identifying the windows as ProLine
Casement, Awning or Transom windows manufactured between 1991-2009; or (3) other documents, such as
purchase orders, establishing that you purchased qualifying ProLine Casement, Awning or Transom windows.
Establishing installation of the windows. To the extent possible, please provide documents establishing the
actual or, if unavailable, the approximate dates of installation of the windows at issue in your Claim Form.
This may include, for example, credit or debit card records, a contract for installation of the windows or canceled
checks to your contractor for window installations.
10
*PEKAWTEN*
3. Documentation of Eligible Damage and Costs. You must submit documentation supporting your claims of
Eligible Damage and the costs to repair such damage.
a. Provide photographs of relevant windows and damage. To the extent possible, for each window/sash that
you claim had or has Eligible Damage, please include photographs of the Eligible Damage for which you are
seeking compensation.
b. For windows/sashes with Eligible Damage that already has been repaired or replaced, please include
documents made or received at or near the time of repair or replacement that verify the nature of the
Eligible Damage, what work was done to remedy the Eligible Damage, the date on which such work was
performed, and the costs of such work. Please identify which documents relate to which Windows (by window
#) that are the subject of this Claim Form. Examples of such documentation include receipts, invoices, credit card
or debit card records, canceled checks or other nancial records showing the amount of money paid for the repair
or replacement and the nature of the repair or replacement performed. You may also submit a signed and dated
statement from the contractor who made the repairs that contains (1) the contractors contact information
(name, address and phone number); (2) state license number (if any); and (3) a description of the actual repairs
performed on each window identied in this Claim Form (by window #) and the costs of such repairs. If you
have yet to obtain an estimate from a contractor, please instruct the contractor, to the extent practicable, to
separate the estimate into the following separate cost categories: costs for product, nishing, installation and
repair of other damage, such as damage to surrounding structure, trim, wallboard, or paint.
c. For windows/sashes with Eligible Damage that have not yet been repaired or replaced, please submit a signed
and dated statement from a contractor who has inspected the windows that contains (1) the contractor’s
contact information (name, address and phone number); (2) state license number (if any); and (3) a
descriptionoftheactualrepairstobeperformedonoraroundeachwindowidentiedinthisClaimForm
(by window #) and the estimated costs of such repairs, separating out, to the extent
practicable, costs for product, nishing, installation and repair of other damage, such as damage to
surrounding structure, trim, wallboard, or paint.
F. LOCATION OF REMOVED WINDOWS
If windows and/or sashes with Eligible Damage
were removed, are the window(s) currently available? Yes No
If “Yes, what is the current location of the window(s):
Mailing Address, including apartment, unit or box number
City State Zip Code
11
*PEKAWELEVEN*
G. IMPORTANT NOTICE REGARDING SUBMISSION TO THE JURISDICTION OF THE COURT
IN ILLINOIS
By the ling of this Claim Form, you hereby submit to the jurisdiction of the United States District Court for the
Northern District of Illinois, Eastern Division, for the purposes of this claim.
H. VERIFICATION OF PROPERLY SUBMITTED CLAIM
The benets provided by the settlement are for otherwise unreimbursed costs and expenses actually incurred or
to be incurred by you related to Eligible Damage covered by the settlement. By submitting this Claim Form, you
verify, under oath and penalty of perjury, that you have not been reimbursed or compensated for any of the Eligible
Damage that you are seeking in this Claim Form.
The benets provided by the settlement DO NOT cover wood deterioration damage that was caused by any of the
following 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 windows to the extent
resulting from natural disaster including, but not limited to re, hurricane, wind, ood, earthquake or
earth movement; (iii) damage resulting from causes unrelated to window performance (such as plumbing
leaks, interior water spills, re 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, modication, or maintenance; (vi) damage
due to an altered or reinstalled window; (vii) damage due to nishes, sealants or caulking not applied by
Defendants or failure to nish the product in a timely manner; (viii) damage caused to wood, medium density
berboard, 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, to the best of your knowledge,
none of the damage for which you are seeking benets in this Claim Form was caused by any of the causes identied
immediately above.
By submitting this Claim Form, you verify, under oath and the penalty of perjury, that, to the best of your knowledge,
all of the damage for which you are seeking benets in the this Claim Form was not caused by any cause other than
water penetrating between the aluminum cladding of the window and the window sash at the corner joint of the
cladding or at the glazing/Sash interface.
By submitting this Claim Form, you verify, under oath and penalty of perjury, that no portion of any Claims that
you ever had, now have, or may in the future have against Pella Corporation, Pella Windows and Doors, Inc. or any
other “Releasee” under the settlement agreement, and no portion of any recovery for which you are submitting this
Claim Form has been assigned or transferred by you to any person, corporation or government body.
By submitting this Claim Form, you verify, under oath and penalty of perjury, that you are not currently employed
by Pella Corporation or Pella Windows and Doors, Inc.
I. SIGNATURE AND DECLARATION
By signing this Claim Form, I declare under penalty of perjury and pursuant to penal code 28 U.S.C.
§1746, that the information I provided in this Claim Form, the verications above, and all supporting
documentation submitted with this Claim Form are true and correct to the best of my knowledge.
Signature of Claimant Date (mm/dd/yyyy)
12
*PEKAWTWELVE*
ADDITIONAL WINDOW FORM
If you have more than two windows/sashes with Eligible Damage, use this form to provide information on the additional
windows/sashes. A separate form must be submitted for each additional window. Please number the windows for
identication purposes.
WINDOW # (write in window number)
a. Window Type: Casement Awning Transom
b.
Glass Etch Number:
and
Product ID Stamp (1991 - 1997 windows) or Unit ID Label (1998 - 2009):
c. Date when Eligible Damage was rst noticed (mm/dd/yyyy):
d. Was Eligible Damage Previously Repaired? Yes No
If “Yes,” date (mm/dd/yyyy):
e. Is/Was Eligible Damage to the full window unit or just to the sash? full unit sash only
f.
Type of Eligible Damage sustained and cost to repair such damage:
Check all categories
of Eligible Damage Costs
**
Cost of Product: $
.
Cost of Finishing: $
.
Cost of Installation: $
.
Cost to Repair Other Property: $
.
(i.e., damage in addition to __________________________
those items listed above)
Total Repair Costs for this window/sash:
$
.
** Important: Please attach the estimate from Pella and/or window contractor. If you have yet to obtain an
estimate from Pella or another window contractor, please instruct the contractor, to the extent
practicable, to separate the estimate into the above categories of Eligible Damage.
g.
If you already replaced this window/sash, was replacement necessary to remediate
water damage to property surrounding the window and to prevent further such damage? Yes No
h.
If you still need to replace this window/sash, is replacement necessary to remediate
water damage to property surrounding the window and to prevent further such damage? Yes No
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