Kostka v. Dickey’s Barbecue Restaurants

Submit a Claim - Page 1

Contact Information:

By completing this Claim Form, you attest that you used a credit or debit card to make a purchase at a Dickey’s Barbecue Pit® location listed in Exhibit B of the Settlement Agreement at any time during the Security Incident Period of April 23, 2019, to October 29, 2020.

Claimant Type:*

First Name:*

Middle Initial:

Last Name:*

Business/Entity Name:*

Representative Name:

All communications from the Notice and Claims Administrator will be directed to the information provided below.

Country:*

Address Line 1:*

Address Line 2:

Address Line 3:

Address Line 4:

Address Line 5:

City:*

State:*

Province:*

ZIP Code:*

Postal Code:*

Phone Number:

Email Address:*

Please Note: Any information that you provide as part of this Settlement—including your name, email address, mailing address, or any other contact information—will not be used by Dickey’s or any third-party for any marketing purpose, or for any other reason that is unrelated to the administration of this Settlement.