Settlement Claim form v3

1 * 312 130 0 000 000*3 1 2 1 3 0 0 0 0 0 0 0 0 United States District Court for the Southern District of New York Hesse, et al. v. Godiva Chocolatier, Inc., Case No. 1:19-cv-00927-AJNMAILED Claim FORM AND INSTRUCTIONSIf you purchased one or more Godiva Chocolate Products* at any time from January 31, 2015 through October 26, 2021, you can complete this Claim Form to be eligible to receive a cash payment under the Settlement .*Godiva Chocolate Products include any product manufactured and sold by Godiva, or sold under the Godiva brand, which contains chocolate. For examples of Godiva Chocolate Products, please see the illustrative list available on the Settlement website: Forms must be completed and submitted by mail, postmarked no later than February 23, 2021 to the following:Hesse, et al. v. Godiva Chocolatier, Settlement AdministratorPO Box 225391 New York, NY 10150-5391 NOTE: If you wish to receive payment electronically, you must complete the Claim Form online at have two options for submitting your Claim .

2 If you do not have Proof of Purchase, you may choose OptionA. If you have Proof of Purchase, you may choose Option B. Under Option A, you can receive $ per Godiva Chocolate product purchased, up to $15 dependingon the number of products you purchased. Under Option B, you can receive $ per Godiva Chocolate product purchased, up to $25 dependingon the number of products you 1: CLAIMANT INFORMATION_____ _____ _____First Name Last Name_____Street Address_____ ___ ___ ___ ___ ___ ___ ___City State Zip Code_____@_____Email Address( ___ ___ ___ ) ___ ___ ___-___ ___ ___ ___Phone Number* 31 213* * CF* * Pa g e 1 o f 3 *31213 CF Page 1 of 3 SECTION 2: Claim AND POTENTIAL CASH BENEFIT Option A.

3 I purchased Godiva Chocolate product (s), but I do not have Proof of you select this Option, please provide how many units of each category of Godiva Chocolate product (s) you purchased between January 31, 2015 through October 26, 2021. NOTE: You can only Claim up to $ CategoryNumber of itemspurchasedGodiva Packaged Chocolates ( , truffle collection, assortedchocolates, etc.)Godiva Chocolate BarsGodiva Individually Wrapped Chocolates ( , G cube,Chocolate Domes, wrapped truffles, wrapped chocolates, etc.)Godiva Chocolate-Covered Snacks (biscuits, pretzels, nuts, and fruits)Godiva In-Store Items (individual truffles, assortedchocolates, chocolate covered strawberries, etc.)Miscellaneous Godiva Chocolate Products ( , hot cocoa,baking mixes, melting chocolates, gift baskets, etc). Option B: I purchased Godiva Chocolate Products, and I do have Proof of you select this option, please include your Proof of Purchase, which can be any receipt, copies of receipts, paid invoice, or other similar types of documentation showing your purchase of any Godiva Chocolate product from either Godiva or any other store.

4 NOTE: You can only Claim up to $25, and you must have Proof of Purchase for each purchase CategoryNumber of itemspurchasedGodiva Packaged Chocolates ( , truffle collection, assortedchocolates, etc.)Godiva Chocolate BarsGodiva Individually Wrapped Chocolates ( , G cube,Chocolate Domes, wrapped truffles, wrapped chocolates, etc.)Godiva Chocolate-Covered Snacks (biscuits, pretzels, nuts,and fruits)Godiva In-Store Items (individual truffles, assortedchocolates, chocolate covered strawberries, etc.)Miscellaneous Godiva Chocolate Products ( , hot cocoa,baking mixes, melting chocolates, gift baskets, etc).* 31 213* * CF* * Page 2 of 3*31213 CF Page 2 of 3 SECTION 3: MARK THE BOX STATING YOUR PREFERRED METHOD OF PAYMENTP ayment via a paper checkPayment via prepaid MastercardSECTION 4: SIGN AND DATE THE AFFIRMATION BELOWI hereby affirm, under penalty of perjury under the laws of the United States of America, each of the following: I personally purchased the Godiva Chocolate Products listed above.

5 I understand that by not opting out of the Settlement , I have given a complete Release of allReleased Claims. The information provided in this Claim Form is true and correct to the best of my DateACCURATE CLAIMS PROCESSING TAKES TIME. THANK YOU FOR YOUR PATIENCE.* 31 213* * CF* * Page 3 of 3*31213 CF Page 3 of 3