1. CLAIMS ADMINISTRATOR F O R O F F I C I A L U S E O N LY
C/O RUST CONSULTING, INC.
P.O. BOX 2727
03
FARIBAULT, MN 55021-9727
I MP O R TA N T LEG AL M AT ERI AL S
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SETTLEMENT FUND PROOF OF CLAIM FORM AND INSTRUCTIONS
United States District Court
For the Southern District of California
In re Groupon Marketing and Sales Practices Litigation
No.3:11-md-02238-DMS-RBB
GROUPON VOUCHER CLASS ACTION SETTLEMENT
TO: PERSONS WHO PURCHASED GROUPON VOUCHERS IN THE UNITED STATES
BETWEEN NOVEMBER 1, 2008 AND DECEMBER 1, 2011
This claim form should be submitted only by persons who purchased Groupon vouchers that have not been redeemed or refunded
and: (1) who purchased Groupon vouchers in the United States between August 22, 2010 and December 1, 2011; or (2) who purchased
Groupon vouchers between November 1, 2008 and December 1, 2011 and are or were residents of, or purchased Groupon vouchers for
redemption in, the following states: Arkansas, California, Connecticut, Florida, Hawaii, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland,
Massachusetts, Michigan, Minnesota, Montana, New Hampshire, New Jersey, New Mexico, North Dakota, Ohio, Oklahoma, Oregon, Rhode
Island, South Carolina, Tennessee, Vermont, Washington. The deadline to submit this claim form has not yet been set. This means that you
must complete and either email this claim form to claims@grouponvouchersettlement.com by the deadline set by the court, if and when
the Settlement is approved, or mail it via First Class mail to Claims Administrator, C/O Rust Consulting, Inc., P.O. Box 2727, Faribault, MN
55021-9727 postmarked by the deadline set by the court. Before you email or mail your claim form, please make sure that it is complete.
Please note that we cannot confirm that the information you transmit to the settlement administrator via email will remain
secure. If you have a concern about sensitive information you are transmitting to the settlement administrator, please consider
submitting this claim form to the settlement administrator by mail.
If you are a representative, assign, heir, executor, administrator, or custodian of the intended recipient of this claim form, you
may complete this form on the Class Member’s behalf. If you are submitting this claim form in a representative capacity, please
include proof of your authority to act on behalf of and to bind the person or entity on whose behalf you are acting.
If and when the settlement is approved and if your claim meets the criteria in Section D of the Settlement Agreement
www.grouponvouchersettlement.com/CourtDocuments.aspx, you will receive a Settlement Voucher, valid for a period
of 130 days from its issue date, to redeem the expired Groupon Voucher(s) that is/are the basis of your claim, for the
goods and/or services at the Merchant Partner identified on the Voucher(s) for the amount of the Customer Purchase
Price, regardless of the expiration date stated on the original Groupon Voucher(s).
History of Purchase
Class Member’s Name:
Class Member’s e-mail address used to purchase Groupon Voucher(s):
Expiration date shown on Groupon Voucher(s): / /
Identity of the merchant and its location referenced on Groupon Voucher(s):
Groupon Voucher Purchase Number(s):
Purchase Price and Face Value of Groupon Voucher(s):
*3326* *CFW* *RUST*

2. *0123456789*
Check ALL that apply. (If you are not able to make all of the statements below, you are NOT eligible to receive a Settlement Voucher:
I am a Groupon Settlement Class Member as defined in the Settlement Agreement.
The Groupon voucher(s) that is/are the subject of the Claim Form was/were purchased between August 22, 2010 and
December 1, 2011 OR was/were purchased between November 1, 2008 and December 1, 2011 by a resident of or for use
at a merchant located in, one of the following states: Arkansas, California, Connecticut, Florida, Hawaii, Illinois, Kansas,
Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, New Hampshire, New Jersey,
New Mexico, North Dakota, Ohio, Oklahoma, Oregon, Rhode Island, South Carolina, Tennessee, Vermont, Washington.
A copy of the Groupon Voucher or a copy of the credit card billing for the purchase of the Groupon Voucher for which I
seek a refund is attached.
The Groupon voucher(s) that is/are the subject of this Claim Form has/have not been redeemed or refunded.
If you meet the eligibility criteria to submit a Claim for a Settlement Voucher but you believe the Merchant listed on the
Groupon Voucher that is the basis of your Claim is no longer in business, please complete the following:
If it is determined that this Claim is otherwise approved but that the Merchant that was listed on the Groupon Voucher is no longer
in business, I wish to receive a cash refund of the purchase price of the Groupon Voucher(s) in the form of a refund check.
I wish to receive the Settlement Voucher:
By e-mail; or
By U.S. mail
Declaration (must be completed to be eligible for settlement benefit)
I have received notice of the class action settlement in this case and I submit this claim form under the terms of the settlement.
I also submit to the jurisdiction of the United States District Court for the Southern District of California with regard to my claim
as a Class Member and for purposes of enforcing the release of claims stated in the Settlement Agreement. The full and precise
terms of the proposed settlement are set forth in the Settlement Agreement. I further acknowledge that I am bound by the terms
of any court judgment that may be entered in this action and may not bring any separate litigation against Groupon, Inc. or against
any entity or person released in the Settlement Agreement related to this action, or that could have been asserted in this action,
as set forth in the Settlement Agreement. I agree to furnish additional information to support this claim if required to do so.
I declare under penalty of perjury that the foregoing information and all information I have submitted in support
of my claim is true and correct, and I agree to abide by the terms of the settlement in this action, including the
acknowledgement that I am bound by the terms of any judgment in this action and may not bring separate litigation
regarding related claims.
Executed this day of , 20 , at , (City, State).
Signature:
Claimant’s Printed Name (First, Middle, Last):
Claimant’s Address:
No./Street/Apt., City, State, Zip Code: ,
If applicable:
Claimant’s Representative’s Printed Name (First, Middle, Last):
Claimant’s Representative’s Address:
No./Street/Apt.,City, State, Zip Code: ,
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