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F O R O F F I C I A L U S E O N LY

This Form Must Be Postmarked by August 17, 2012

03

CLAIM FORM

Name:

Address: City: State:

Zip Code:

Phone Number: (

)

-

Email:

@

IBO Number (if available):

Section I: Instructions If you were a Quixtar Independent Business Owner (“IBO”) after January 1, 2003, but you resigned as an IBO by February 21, 2012, you may be eligible to receive: • Up to $75 retail value of free Quixtar products (see SECTION II: PRODUCT CREDIT); • Up to a 20% refund (maximum $2,000) of your verifiable expenditures on business support materials

(see SECTION III: CASH REFUND FOR BSM EXPENDITURES); and/or

• Compensation for special hardships you may have suffered because of your participation in Quixtar

(see SECTION IV: HARDSHIP FUND).

To determine your eligibility for these benefits, complete the applicable section(s) of this Claim Form, sign and date it, and mail it, postmarked no later than August 17, 2012, to: Claims Administrator PO Box 8035 Faribault, MN 55021-9435 It is important that all of the information you provide in this Claim Form is true, accurate, and complete. You may be required to provide documentation supporting the answers you have provided. Persons who submit false or fraudulent claims will not be eligible for compensation. NOTE: If you were not a Quixtar Independent Business Owner (“IBO”) during the period outlined above, or if you are currently a Quixtar IBO, you are not entitled to compensation under the Settlement Agreement.

*2942*

*CFW*

*RUST*


SECTION II: PRODUCT CREDIT Complete this Section ONLY if you paid an initial registration fee to become a Quixtar IBO, you did not renew your involvement with Quixtar beyond your first year, and you have not had your registration fee refunded to you. By checking here, I certify that I paid an initial registration fee to become a Quixtar IBO, I did not renew my involvement with Quixtar beyond my first year, and I have not had my registration fee refunded to me. Please rank the following twelve product bundles in order of preference (detailed information about each product is available at www.QuixtarClass.com): Family Supplements Supplements and skin care Supplements and skin care (oily skin) Double X supplement Artistry and Nutrilite - Women Tolsom and Nutrilite - Men Laundry care and immune supplements Laundry care and Him & Hers supplements Weight management Personal care Energy Sports

1 = First 2 = Second 3 = Third 4 = Fourth 5 = Fifth 6 = Sixth 7 = Seventh 8 = Eighth 9 = Ninth 10 = Tenth 11 = Eleventh 12 = Twelfth

SECTION III: CASH REFUND FOR BSM EXPENDITURES Complete this Section ONLY if you have receipts, credit card statements, or other forms of proof that you spent at least $100 more on business support materials (books, tapes, and function tickets) than you received from re-selling business support materials. By checking here, I certify that the amount I spent on business support materials is at least $100 more than I received from re-selling business support materials. I am submitting copies of my receipts, credit card statements, and/or other forms of proof of purchase along with this Claim Form demonstrating my net expenditures on business support materials. How much do your receipts, credit card statements, and other forms of proof show you spent on business support materials?

$

,

.

How much money, if any, did you receive from re-selling business support materials?

$

,

.

Did you receive a profit from operating your Quixtar business? If you are submitting business support materials as a form of proof, do you attest that you purchased the materials while you were an IBO for the purpose of growing your business?

Yes No Yes No

SECTION IV: HARDSHIP FUND Complete this Section ONLY if you filed for personal bankruptcy because of your involvement in Quixtar, AND/OR if you are able to demonstrate that you lost at least $10,000 from operating your Quixtar business. By checking here, I certify that I filed for personal bankruptcy because of my involvement in Quixtar. I have attached to this Claim Form the following: • • •

Copies of documents showing that I applied for personal bankruptcy; A detailed statement explaining how and why my involvement in Quixtar caused me to file for personal bankruptcy; and Documents showing how much money I lost because of my involvement in Quixtar.

By checking here, I certify that I am able to demonstrate – through tax returns or other similar form of proof – that I lost at least $10,000 from operating my Quixtar business. I have attached to this Claim Form the following: • • •

Copies of tax returns or similar documents showing that I lost at least $10,000 from operating my Quixtar business; A detailed statement explaining how and why my business lost at least $10,000; and Other documents sufficient to show how much money I lost because of my involvement in Quixtar.

SECTION V: SIGN I swear that I was a Quixtar Independent Business Owner at some time after January 1, 2003; that I am not a current Quixtar Independent Business Owner; that I quit my involvement with Quixtar on or before February 21, 2012; and that all information provided in this Claim Form, including any information provided in enclosed documents, is true, accurate, and complete to the best of my knowledge. By signing this Claim Form, I acknowledge that the Claims Administrator may ask Quixtar to provide certain information related to my Quixtar-related business (including tax forms and other financial data) to verify my Claim. Signature:

Print Name:

Date:

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