Maytag Neptune Claims Administrator
P.O. Box 6198 Novato, CA 94948-6198 1-866-288-0515

CLAIM FORM

I. CLAIMANT INFORMATION
Please Print: Name: Address: City:

Area Code

State:

Daytime Telephone

Zip Code:

Evening Telephone

Cellular
Email: Model Number of Maytag Neptune Washing Machine: (This includes any model including stackables) Serial Number of Maytag Neptune Washing Machine: Date of Purchase of Maytag Neptune Washing Machine: II. CLAIM FOR WASHING MACHINE PURCHASE CERTIFICATE/REPAIR REQUEST Under the Settlement Agreement, at its election, Maytag may attempt to repair any of the below-listed Class Claims at no cost to you even if your warranty has expired. This does not extend any existing Maytag warranties. If Maytag cannot fix your Class Claim(s) or elects not to repair your machine, Maytag will issue you a Washing Machine Purchase Certificate good towards the purchase of a new Top-Load Neptune Washing Machine. See paragraph 8 on page 3 of the Notice for details. To be eligible for a repair or Washing Machine Purchase Certificate, you must complete this section of the Claim Form. 1. As listed below, I have experienced the following Class Claim(s) with my Neptune Front-Load Washing Machine which required repair of the machine: odor, mold or mildew door latch/wax motor motor control related circuit board failure 2. Has your Neptune Front-Load Washing Machine been serviced?
3. If yes, please provide the dates the Washing Machine was serviced and check the box identifying the Class Claim(s) on that repair date: Date of Service odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew odor/mold/mildew Class Claims door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor door latch/wax motor motor control motor control motor control motor control motor control motor control motor control motor control motor control motor control circuit board circuit board circuit board circuit board circuit board circuit board circuit board circuit board circuit board circuit board
4. Enclosures Required: a. Proof of service: include a repair bill, invoice, or service report. b. Proof of out-of-pocket costs: repair bill, invoice or service report marked paid, or other proof of payment or receipt. c. Proof of Neptune Front-Load Washing Machine purchase date (dealer invoice or other evidence of the model and purchase date). Filing deadline for a Washing Machine Purchase Certificate/Repair Request Claim: Postmarked August 9, 2005.
Complete and sign this Claim Form on Page 2

MCM_POC_040819

III. CLAIM FOR REPAIR REIMBURSEMENT If you are filing a claim for reimbursement of out-of-pocket costs incurred for repair of one of the four Class Claims listed below with your Maytag Neptune Front-Load Washing Machine, complete this section of the Claim Form. Please describe each out-of-pocket cost for a repair of your washing machine. If you are claiming more than three repairs, make copies of this side of the claim form.
1. Date of Repair: Class Claims: odor/mold/mildew Name of repair company: door latch/wax motor motor control circuit board
Out-of-pocket Cost: $__________________ Any concession or payment made by Maytag: $_________________ ---------------------------------------------------------------------------------------2. Date of Repair: Class Claims: odor/mold/mildew Name of repair company: door latch/wax motor motor control circuit board

Out-of-pocket Cost: $__________________ Any concession or payment made by Maytag: $_________________ ---------------------------------------------------------------------------------------3. Date of Repair: Class Claims: odor/mold/mildew Name of repair company: door latch/wax motor motor control circuit board
Out-of-pocket Cost: $__________________ Any concession or payment made by Maytag: $_________________ ---------------------------------------------------------------------------------------Please note that you may receive a portion of your reimbursement costs in the form of an Appliance Purchase Certificate. The Appliance Purchase Certificate may be used to purchase a Major Maytag Appliance.
Enclosures Required: Proof of out-of-pocket costs -- for each repair reimbursement you are claiming include a repair bill, invoice, service report or other proof of payment or receipt indicating the date and your payment. Filing deadline for a Repair Reimbursement Claim: Postmarked May 2, 2005. IV. CLAIM FOR REPLACEMENT COSTS In order to qualify for this benefit, you must have purchased a new replacement washing machine due to one of the four Class Claims listed below with your Maytag Neptune Front-Load Washing Machine. 1. Did you purchase a new washer to replace your Neptune Front-Load Washing Machine due to problems with your Neptune Washing Machine?
2. I experienced the following problems with my Neptune Front-Load Washing Machine which required replacement of the machine: odor/mold/mildew door latch/wax motor motor control circuit board 3. Cost incurred for the replacement: $ Please note that you may receive a portion of your replacement costs in the form of an Appliance Purchase Certificate. These Appliance Purchase Certificates may be used to purchase a Major Maytag Appliance. 4. Enclosures Required: Proof of purchase of new machine, i.e., invoice marked paid, credit card bill, or cancelled check and proof of ownership of replaced Maytag Neptune. The filing deadline for a Replacement Costs Claim: Postmarked May 2, 2005. V. CERTIFICATION I/we hereby swear or attest under penalty of perjury that all the information that I/we supplied in this Claim Form is true and correct. If more than one owner, this Claim Form must be signed by all owners. Signature of Owner Signature of Owner Date Date Signature of Owner Signature of Owner Date Date
THIS PROOF OF CLAIM MUST BE SUBMITTED NO LATER THAN THE FILING DEADLINE STATED FOR EACH TYPE OF CLAIM, AND MUST BE MAILED TO: Maytag Neptune Claims Administrator, P.O. Box 6198 Novato, CA 94948-6198. A Claim Form received by the Claims Administrator shall be deemed to have been submitted when posted, if a postmark is indicated on the envelope and it is mailed first class, and addressed in accordance with the above instructions. In all other cases, a Proof of Claim and Release shall be deemed to have been submitted when actually received by the Claims Administrator. No acknowledgment will be made as to the receipt of Claim Forms. You should be aware that it will take an amount of time to process fully all of the claims and to administer the Settlement. This work will be completed as promptly as time permits, given the need to investigate and tabulate each Claim Form. Please notify the Claims Administrator of any change of address. ACCURATE CLAIMS PROCESSING TAKES TIME. THANK YOU FOR YOUR PATIENCE. Reminder Checklist:

1. 2. 3. 4. 5. 6.

Please personally sign this claim form. Attach copies of supporting documentation. Keep a copy of the completed Claim Form for your records. If you desire an acknowledgment of receipt of your Claim Form, please send it Certified Mail, Return Receipt Requested. If you move, or if this Claim Form was sent to you at an old or incorrect address, please provide us with your new address. If you have any questions concerning this Claim Form, contact the Claims Administrator by writing: Maytag Neptune Claims Administrator, P.O. Box 6198, Novato, CA 94948-6198. 7. Under the terms of the Settlement Agreement, depending on the number of claims submitted, persons making a claim under Sections III or IV of this Claim Form may receive a pro rata cash distribution and an Appliance Purchase Certificate for the entire award amount.
Class Counsel urges you to send a completed claim form as soon as possible to assist us in the administrative process and to expedite your claim. If you need help filling out this Claim Form, contact the Maytag Neptune Claims Administrator at 1-866-288-0515. -2-