YOU MUST COMPLETE THIS CLAIM FORM IN ORDER TO RECEIVE ANY BENEFITS. THIS CLAIM FORM MUST BE RECEIVED BY OCTOBER 15, 2007.
Name of owner of facsimile number:
_________________________________________________________________
Address:
_________________________________________________________________
Fax number (including area code):
_________________________________________________________________
Telephone number:
_________________________________________________________________
I submit this Claim Form under penalties of perjury and state that I am (or the business or entity I represent is) the only person or entity entitled to receive the settlement benefit being sought and that I (and/or the business or entity that I represent) had ownership, authority or control over the fax number listed above on or after November 7, 1999. I swear or affirm that I received the above-described facsimile advertisement on or after November 7, 1999 and I do not have an established business relationship with Body Wise International, Inc. or Diane Paulson. I also did not give consent to the sending of the facsimile to me.
_____________________________
Signature
_____________________________
Print Name