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Amiri v. My Pillow - Case No. CIVDS1606479


Subject to the terms of the Settlement Agreement, and pending final approval by the Court, to request a settlement payment, please complete this form and return it by December 26, 2016.


Fill in the following blanks with complete information.

To request a $5 refund, please return your My Pillow product, provide the original purchase receipt, or sign this Claim Form under penalty of perjury. If you purchased three or more My Pillow products during your initial purchase and you write “Three+” on your original purchase receipt that you scan and upload with your Claim Form, you may be eligible to receive an additional benefit of up to $5, depending on the number of people who submit a Claim Form. There is a maximum of one Claim Form per household.

If you would like to upload your receipt, please do so here:

    I swear under penalty of perjury of the laws of the United States that I purchased My Pillow product(s) between April 26, 2012 and October 13, 2016 in the United States and that all the information on this form is true and correct to the best of my knowledge.

    The Claims Administrator will review all online claim forms that are submitted on or before December 26, 2016. Claim forms that are not timely submitted will be rejected. Invalid claim forms and illegible claim forms may be rejected. The Claims Administrator is entitled to confirm information supplied in claim forms to determine eligibility. Visit or call 1-877-595-9314 for further information on the Settlement.