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Advance Trans Claim

CLAIM FORM AND RELEASE

In order to participate in the settlement described in the notice, you must complete and submit this claim form and tax form. YOUR COMPLETED CLAIM FORM MUST BE RECEIVED BY AUGUST 2, 2024.

Release of Claims

I attest, under penalty of perjury, that the information below is true and correct to the best of my memory. In addition, I understand and agree that, in consideration for my receipt of a share of the settlement funds in this case, I am releasing Advance Transportation Systems, LLC, its predecessors, successors, parents, subsidiaries, divisions and affiliates of whatever form, and all those entities’ current and former owners, partners, stockholders, managing agents, members, agents, directors, officers, employees, principals, heirs, representatives, attorneys, accountants, auditors, consultants, insurers and reinsurers, benefits plans, plan fiduciaries and administrators, any person acting directly or indirectly in the interest of Advance Transportation Systems, LLC in relation to its employees, and all persons acting by, through, under or in concert with any of them, of all claims based upon or that arise out of the facts, acts, transactions, occurrences, events, or omissions alleged in the lawsuit entitled Andrews, et al. v. Advance Transportation Systems, LLC, et al., Case No. 1:22-cv-01705, and that arose at any time between April 1, 2012, and January 30, 2024, including, but not limited to, all claims, rights, demands, liabilities, and causes of action for wages, misclassification, hours worked, and improper deductions that were or could have been asserted under federal, state, local, or other applicable law by or on behalf of the putative class in that lawsuit.

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.

CONTACT INFORMATION

FIRST NAME:

LAST NAME:

ADDRESS:

UNIT/APT:

CITY:

STATE:

ZIP:

PHONE:

EMAIL:

SIGN DATE:

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

Please print your Social Security Number (SSN):

Select One:

Single

Married

Married, but withhold at higher Single rate

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:

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
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
I am a U.S. person (including a U.S. resident alien)

Date Signed:

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.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

June 3, 2024 12:36 pm EST

Advance Trans Claim Uploaded by Optime Administration, LLC - [email protected] IP 73.114.220.204, 132.148.110.4, 0.0.0.0, 73.114.220.204