CLAIM FORM & RELEASE

In order to participate in the settlement that is described in the Notice and claim a share of the settlement’s proceeds, you must complete, sign and submit this claim form.

DEADLINE: Your completed Claim Form & Release and tax information must be received by no later than April 16, 2026.

DO NOT ALTER THE LANGUAGE BELOW.  If you alter this language, your claim form will not be valid and will not be accepted.

Release of Claims:

In consideration for my receipt of a share of settlement funds, I forever release and discharge the Releasees of any actions, claims, demands, suits, or causes of action, known or unknown, including for damages, rights, liabilities, penalties, attorneys’ fees, costs, expenses, multiple damages, and interest, that were asserted or could have been asserted in the Pending Case or that are based upon the facts alleged in the Pending Action including but not limited to any claims under the Massachusetts Wage Act, up to June 1, 2025.

Personal Information:

First Name:  

Last Name:  

Street Address:

Apt/Unit:

City:

State:

Zip Code:

Home or Mobile Phone:

E-mail (optional):  

By signing below, I declare and verify that I have read this Claim Form, and that I agree to participate in the Settlement on the terms described herein, including the Release of Claims set forth above.

Date Signed:

Optime Administration, LLC – Substitute IRS Form W-9 & W4

Please print your Social Security Number (SSN):

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Select One: 

Total number of allowances you are claiming:  

Additional amount, if any, you want withheld from settlement payment: 

Print your name as shown on your tax return:  

Certification:

Under penalty of perjury, I certify that:

1. The social security number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
3. I am a U.S. person (including a U.S. resident alien)

Note: If you have been notified by the IRS that you are subject to backup withholding, you must cross out line 2 above. The IRS does not require your consent to any provision of this document other than this Form W-9 certification to avoid backup withholding.

Date Signed: