Betorina et al v. Randstad US, L.P.

Filing 41

STIPULATION AND ORDER RE: CLASS NOTICE. Final Approval of Settlement Hearing set for 8/3/2017 01:30 PM in Courtroom 5, 17th Floor, San Francisco before Edward M. Chen.. Signed by Judge Edward on 4/14/17. (bpfS, COURT STAFF) (Filed on 4/14/2017)

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BLUMENTHAL, NORDREHAUG & BHOWMIK
Norman B. Blumenthal (SBN 068687)
Kyle R. Nordrehaug (SBN 205975)
Aparajit Bhowmik (SBN 248066)
Molly A. DeSario (SBN 230763)
Piya Mukherjee (SBN 274217)
2255 Calle Clara
La Jolla, California 92037
Telephone:
[phone]
Facsimile:
(858) 551-21232

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Attorneys for Plaintiffs
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SEYFARTH SHAW LLP
Andrew M. McNaught (SBN 209093)
[e-mail]
Michael A. Wahlander (SBN 260781)
[e-mail]
Duwayne A. Carr (SBN 299136)
[e-mail]
560 Mission Street, 31st Floor
San Francisco, California 94105
Telephone:
[phone]
Facsimile:
[phone]

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Attorneys for Defendant
RANDSTAD US, L.P.

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UNITED STATES DISTRICT COURT

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NORTHERN DISTRICT OF CALIFORNIA

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MARCUS BETORINA, JOSEPH DIAZ, and
FRED BELL, individuals on behalf of themselves
and on behalf of all persons similarly situated,

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Plaintiffs,

Case No. 3:15-CV-03646-EMC
STIPULATION AND [PROPOSED]
ORDER RE: CLASS NOTICE, CLAIM
FORM AND FINAL APPROVAL
HEARING DATE

v.
RANDSTAD US, L.P., a Limited Partnership; and
Does 1 through 50, inclusive,

Judge: Hon. Edward M. Chen
Dept.:
Ctrm. 5

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Defendant.
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Plaintiffs Marcus Betorina, Joseph Diaz, and Fred Bell (“Plaintiffs”) and Defendant Randstad

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US, L.P. (“Randstad”) (collectively “the Parties”), by and through their respective counsel, stipulate as

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follows:
STIPULATION AND [PROPOSED] ORDER RE: CLASS NOTICE, CLAIM FORM AND FINAL APPROVAL
HEARING DATE / CASE NO. 3:15-CV-03646-EMC

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1.

On April 6, 2017, the Court entered an order granting preliminary approval of the Parties’

proposed Settlement Agreement [Doc. No. 38].
2.

As part of that order, the Court ordered the Parties to file an amended Class Notice and

Claim Form with certain revisions.
3.

The Parties have made the ordered revisions to the Class Notice and Claim Form and the

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revised Class Notice and Claim Form are attached hereto as Exhibit A, which are now submitted for the

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Court’s approval.

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4.

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The Parties also request that the Court set the Final Approval Hearing for a date on or

after August 3, 2017, which date shall be included in the Class Notice.
IT IS SO STIPULATED.
DATED: April 14, 2017

Respectfully submitted,

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BLUMENTHAL, NORDREHAUG &
BHOWMIK

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BY: /s/ Kyle R. Nordrehaug
Kyle R. Nordrehaug

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Attorneys for Plaintiff
MARCUS BETORINA, JOSEPH DIAZ and
FRED BELL

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DATED: April 14, 2017

Respectfully submitted,

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SEYFARTH SHAW LLP

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BY: /s/ Michael A. Wahlander
Michael A. Wahlander

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Attorneys for Defendant
RANDSTAD US, L.P.

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ATTESTATION PURSUANT TO LOCAL RULE 5-1(i)(3)
I, Kyle Nordrehaug, attest that concurrence in the filing of this stipulation has been obtained
from the signatory, Michael Wahlander, counsel for Defendant.
DATED: April 14, 2017

By:

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/s/ Kyle Nordrehaug
Kyle Nordrehaug

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STIPULATION AND PROPOSED ORDER TO CONTINUE CASE MANAGEMENT CONFERENCE / CASE NO. 3:15CV-03646-EMC

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[PROPOSED ORDER]

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Pursuant to the Parties’ stipulation and good cause appearing therefore, the Court orders as

August 3
1:30 p.m
The Final Approval Hearing is set for _____________________, 2017 at ___________.

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dwar
Judge E

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Hon. Edward M. Chen
United States District Court Judge
Northern ANTED California
GR District of

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April 14
DATED: ____________, 2017

UNIT
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S DISTRICT
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________________________________

IT IS SO ORDERED.

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The revised Class Notice and Claim Form attached to the stipulation as Exhibit A are approved.

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follows:

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STIPULATION AND PROPOSED ORDER TO CONTINUE CASE MANAGEMENT CONFERENCE / CASE NO. 3:15CV-03646-EMC

EXHIBIT “A”

NOTICE OF PENDENCY OF CLASS ACTION SETTLEMENT
AND HEARING DATE FOR COURT APPROVAL
(Betorina, et al. v. Randstad US, L.P., U.S. District Court,
Northern District of California Case No. 3:15-CV-03646 EMC)
YOUR LEGAL RIGHTS MAY BE AFFECTED WHETHER YOU ACT OR DO NOT ACT. PLEASE
READ THIS NOTICE CAREFULLY.
SUMMARY OF YOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT:
Submit a Claim Form
and Receive a
Payment

To get money from the settlement, you MUST timely submit a
completed Claim Form. Your Claim Form accompanies this Notice.
Your estimated Individual Settlement Share is stated on the
accompanying Claim Form.
In exchange for the settlement payment, you will release claims against
the Defendant as detailed below.

Exclude Yourself

To exclude yourself, you must send a letter to the Settlement
Administrator as provided below. If you request exclusion, you will
receive no money from the Settlement.
Instructions are set forth below.

Object

Write to the Court about why you do not like the settlement. If your
object, you can still submit a Claim Form and receive a payment.
Directions are provided below.

Do Nothing

If you do nothing, you will not receive money from the settlement. You
will still release certain claims against the Defendant.

1. Why did I get this Notice?
A proposed class action settlement (the “Settlement”) in Betorina, et al. v. Randstad US, L.P., Case No. 3:15-CV03646 EMC, pending in the United States District Court for the Northern District of California (the “Court”) has
been reached between Plaintiffs Marcus Betorina, Fred Bell, and Joseph Diaz (“Plaintiffs”) and Defendant Randstad
US, L.P. (“Defendant”), and has been granted preliminary approval by the Court. You may be entitled to receive
money from this Settlement.
You have received this Notice because you have been identified as a member of the Class, which is defined as:
All individuals who worked for Defendant Randstad US, L.P. as Security Guards who were placed
out of Randstad business unit 14023, and classified as non-exempt employees, from February 13,
2011 to August 8, 2016.
This Notice explains the lawsuit, the Settlement, and your legal rights. It is important that you read this Notice
carefully as your rights may be affected by the Settlement.
2. What is this class action lawsuit about?
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On February 13, 2015, Plaintiffs initially filed a class action lawsuit in the Superior Court for the County of
Alameda, Case No. RG15758487, entitled Betorina, et al v. Randstad US, L.P. The complaint was subsequently
amended on April 16, 2015. Defendant removed the lawsuit to the United States District Court for the Northern
District of California on August 10, 2015 where the lawsuit has proceeded as Case No. 3:15-CV-03646 EMC (the
“Action”).
On February 15, 2017, Plaintiffs attached the Second Amended Complaint to the pending motion for preliminary
approval, which the Court recognized as the operative complaint in the Order dated April 6, 2017. In the Second
Amended Complaint, Plaintiffs allege that Defendant violated wage and hour laws and seek, on each Plaintiff’s own
behalf, and on behalf of the Class, meal and rest period premium pay, unpaid wages and interest thereon, penalties,
liquidated damages, injunctive and other equitable relief, and reasonable attorneys’ fees and costs, under, inter alia,
Title 8 of the California Code of Regulations, Business & Professions Code §§ 17200, et seq., various Industrial
Welfare Commission Wage Order(s), California Code of Civil Procedure §1021.5, and various provisions of the
California Labor Code.
Defendant denies and disputes all such claims, and avers that its security guards were provided meal and rest breaks,
were properly paid any premiums owed for missed meal and rest breaks, were properly paid all wages and overtime
as due, were provided accurate wage statements, and paid all wges owed on termination. Defendant denies that it
violated the law in any way. Defendant has and will assert numerous defenses to these claims. Nothing in this
Notice, or the Settlement itself, or any actions to carry out the terms of the Settlement mean that the Defendant
admits any fault, guilt, negligence, wrongdoing or liability whatsoever. The Court has made no findings regarding
the above claims.
The Court granted preliminary approval of the Settlement on <<INSERT PRELIMINARY APPROVAL DATE>>.
At that time, the Court also preliminarily approved Plaintiffs to serve as the Class Representatives, and the law firm
Blumenthal, Nordrehaug & Bhowmik to serve as Class Counsel.
3. What are the terms of the Settlement?
Gross Settlement Fund. Defendant has agreed to pay an “all in” amount of Three Hundred Fifty Thousand Dollars
($350,000) (the “Gross Settlement Fund”) to fund the settlement of this Action. The Gross Settlement Fund is
comprised of a Net Settlement Fund for the Class, an award of attorney’s fees and costs, settlement administration
expenses, a PAGA payment, and service awards to the Class Representatives. Defendant’s portion of payroll taxes
shall remain the responsibility of Defendant.
Defendant shall fully fund the Gross Settlement Fund to the Settlement Administrator within fifteen (15) days of the
Effective Date. The “Effective Date” is the date upon which Final approval of the Settlement Agreement is granted
by the Court and the Court’s Judgment approving the Settlement becomes Final.
Amounts to be Paid From the Gross Settlement Fund. The Court has tentatively approved certain payments to be
made from the Gross Settlement Fund as follows, which will be subject to final Court approval, and which will be
deducted from the Gross Settlement Fund before settlement payments are made to Class Members who timely
submit valid Claim Forms (“Qualified Claimants”):
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Settlement Administration Expenses. Payment to the Settlement Administrator, estimated not to exceed
$19,000, for expenses, including expenses of notifying the Class of the Settlement, processing opt outs and
claim forms, and distributing settlement payments.

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Attorneys’ Fees and Costs. Payment to Class Counsel of reasonable attorneys’ fees not to exceed $87,500
(25% of the Gross Settlement Fund) for reasonable attorneys’ fees, and an additional amount to reimburse
actual litigation costs billed to the Plaintiffs not to exceed $10,000. Class Counsel has been prosecuting the
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Action on behalf of Plaintiffs and the Class on a contingency fee basis (that is, without being paid any
money to date) and has been paying all litigation costs and expenses.
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Service Awards. Service Awards of Ten Thousand Dollars ($10,000.00) each to the Plaintiffs, or such
lesser amount as may be approved by the Court, to compensate them for services on behalf of the Class in
initiating and prosecuting the Action, and for the risks they undertook. This payment is in addition to
whatever payments the Plaintiffs are otherwise entitled to as a Class Member.



PAGA Payment. A payment of $3,500 relating to Plaintiffs’ claim under the Private Attorney General’s Act
(“PAGA”), $2,635 of which will be paid to the State of California’s Labor and Workforce Development
Agency (“LWDA”). The remaining $875 will be distributed to Class Members as part of the Net Settlement
Fund.

Calculation of Payments to Qualified Claimants. After all the above payments of the court-approved Attorney’s
Fees and Costs, the Service Awards, the PAGA payment to the LWDA, and the employer’s share of payroll taxes
and Administration Costs are deducted from the Gross Settlement Fund, the remaining portion, the “Net Settlement
Fund” shall be distributed to class members who submit a valid Claim Form” (“Qualified Claimants”). Each
Qualified Claimant shall be entitled to receive a pro rata portion of the Net Settlement Fund (his/her “Individual
Settlement Share”) calculated based upon the number of workweeks in which the member worked during the
Settlement Period, divided by the total number of workweeks worked by all Settlement Class Members during said
period.
You must submit a valid Claim Form to the Settlement Administrator by ______________, 2017 to receive
your Individual Settlement Share. Your Claim Form accompanies this Notice and must be fully completed
and signed to be valid.
Tax Matters. Settlement payments to an Qualified Claimants will be designated as payment for and allocated as
thirty-three percent (33%) of the Individual Settlement Share that is distributed to each Qualified Claimants will be
considered wages, thirty-three percent (33%) will be considered interest, and thirty-four percent (34%) percent will
be considered penalties. The employee portion of all applicable income and payroll taxes, as well as the taxes on the
penalties and interest damages payment, will be the responsibility of the Class Members. You may wish to consult
a tax advisor concerning the tax consequences of the payments received under the Settlement.
Conditions of Settlement. This Settlement is conditioned upon the Court entering an order granting final approval
of the Settlement and entering judgment.
4. What Do I Release Under the Settlement?
Released Class Claims. Upon the final approval by the Court of this Settlement Agreement, and except as to such
rights or claims as may be created by this Settlement Agreement, the Settlement Class Members release Defendant,
its current or former subsidiaries, affiliates, owners, parents, predecessors, insurers, agents, employees, partners,
successors, assigns, officers, officials, directors, employers, attorneys, personal representatives, executors, and
shareholders, including their respective pension, profit sharing, savings, health, and other employee benefit plans of
any nature, the successors of such plans, and those plans’ respective current or former trustees and administrators,
agents, employees, and fiduciaries (“Releasees”), of and from any and all claims, rights, demands, charges,
complaint, causes of action, obligations or liability of any and every kind that were alleged in any version of any
complaint filed in the Action or in the Second Amended Complaint which occurred during the Settlement Period,
and expressly excluding all other claims, including claims for wrongful termination, unemployment insurance,
disability, workers’ compensation, and claims outside the Settlement Period, except that Settlement Class Members
who do not submit signed Claim Forms will not release their claims under the Fair Labor Standards Act (“Released
Class Claims”).
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This means that, if you do not timely and formally exclude yourself from the settlement, you cannot sue, continue to
sue, or be part of any other lawsuit against Defendant and the Releasees about the legal issues resolved by this
Settlement. It also means that all of the Court’s orders in this Action will apply to you and legally bind you.
5. How much will my payment be?
Your estimated Individual Settlement Share is stated on the accompanying Claim Form.
If you wish to challenge the information set forth in the Claim Form, then you must timely submit a signed and
completed Claim Form and complete the dispute section of the Claim Form along with supporting documents to the
Settlement Administrator at the address provided on the Claim Form postmarked no later than the stated deadline.
6. How can I get a payment?
To get money from the settlement, you MUST timely submit a completed Claim Form. Your Claim Form
accompanies this Notice. If you are a Class Member and you submit a valid Claim Form post-marked on or
before [date], you will receive a settlement payment and will be bound by the settlement. The judgment will bind
all members of the Class who do not request exclusion.
Class Members who submit a Claim Form and become Qualified Claimants will opt in to the FLSA claims and
agree to the release of FLSA claims as outlined in the Claim Form. A check for your settlement payment will be
mailed to the same address as this Notice. If your address is incorrect or has changed, you must notify the
Settlement Administrator. The Settlement Administrator is: _________________ (800) __________.
The Court will hold a hearing on (date), 2017 to decide whether to approve the Settlement. If the Court approves
the Settlement and there are no objections or appeals, payments will be mailed within a couple months after this
hearing. If there are objections or appeals, resolving them can take time, perhaps more than a year. Please be
patient.
7. What if I don’t want to be a part of the Settlement?
If you do not wish to participate in the Settlement, you may exclude yourself from the Settlement or “opt out.” If
you opt out, you will receive no money from the Settlement, and you will not be bound by its terms.
To opt out, you must submit to the Settlement Administrator, by First Class Mail, a written, signed and dated
request to opt-out postmarked no later than _____________, 2017. The request to opt-out must state in substance: “I
have read the Class Notice and I wish to opt-out of the class action and settlement of the case Betorina, et al. v.
Randstad US, L.P., Case No. 3:15-CV-03646” The request to opt-out must contain your name, address, signature
and the last four digits of your Social Security Number for verification purposes. The request to opt-out must be
completed by you. No other person may opt-out for a member of the Class.
The address for the Settlement Administrator is ________________________________________. Written requests
for exclusion that are postmarked after
, 2017, or are unsigned by an individual Class Member, will
be rejected, and those Class Members will remain bound by the Settlement and the release described above. If you
submit both a Claim Form and a request for exclusion, only the Claim Form will be accepted and the request for
exclusion will be disregarded.
8. How do I tell the Court that I don’t like the Settlement?
Any Class Member, who has not opted out and believes that the Settlement should not be finally approved by the
Court for any reason, may object to the proposed Settlement. Objections must be in writing and state the Class
Member’s name, current address, telephone number, and describe why you believe the Settlement is unfair and
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whether you intend to appear at the final approval hearing. All objections or other correspondence must also state
the name and number of the case, which is Betorina v. Randstad, in the United States District Court for the Northern
District of California, Case No. 3:15-CV-03646 EMC.
The objections must be sent to the Settlement Administrator postmarked no later than ________________,
2017. Objections to the Settlement must also be submitted to the Court either by mailing them to the Class Action
Clerk, United States District Court for the Northern District of California, Philip Burton Federal Building & United
States Courthouse, 450 Golden Gate Avenue, San Francisco, CA 94102, or by filing them in person at any location
of the United States District Court for the Northern District of California
To object to the Settlement, you must not opt out, and if the Court approves the Settlement, you will be bound by
the terms of the Settlement in the same way as Class Members who do not object. If you object, you must still
submit a Claim Form in order to receive money from the Settlement. Any Class Member who does not object
in the manner provided in this Notice shall have waived any objection to the Settlement, whether by appeal or
otherwise.
The address for the Settlement Administrator is:
Betorina v. Randstad Settlement Administrator
c/o _____________________
___________________
___________________
___________________
The addresses for Parties’ counsel are as follows:
Class Counsel:
Norman Blumenthal
Blumenthal, Nordrehaug & Bhowmik
2255 Calle Clara
La Jolla, CA 92037
Tel: [phone] / Fax: [phone]
Email: [e-mail]
Website: www.bamlawca.com

Counsel for Defendant:
Andrew M. McNaught
Michael A. Wahlander
SEYFARTH SHAW LLP
560 Mission Street, Suite 3100
San Francisco, CA 94105

9. When and where will the Court decide whether to approve the Settlement?
The Court will hold a Final Approval Hearing at 00:00 AM/PM on __________, 2017, at the United States District
Court, located at 450 Golden Gate Avenue, San Francisco, CA 94102 in Courtroom 5 before Judge Edward M.
Chen. At this hearing the Court will consider whether the Settlement is fair, reasonable, and adequate. The purpose
of this hearing is for the Court to determine whether to grant final approval to the Settlement. If there are
objections, the Court will consider them. The Court will listen to people who have made a timely written request to
speak at the hearing. Class Members may make an appearance through an attorney. To speak at the hearing, you
must submit a written request stating your intention to appear at the Final Approval Hearing to the Settlement
Administrator postmarked no later than ________________, 2017. This hearing may be rescheduled by the Court
without further notice to you. You are not required to attend the Final Approval Hearing, although any Class
Member is welcome to attend the hearing.
10. How do I get more information about the Settlement?
You may call the Settlement Administrator at ____________ or write to Betorina v. Randstad Settlement
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Administrator, c/o ____________________________; or contact Class Counsel at 1-858-551-1223.
This notice summarizes the proposed settlement. More details are in the Settlement Agreement. You may receive a
copy of the Settlement Agreement, the Final Judgment or other Settlement documents by writing to Blumenthal,
Nordrehaug & Bhowmik, 2255 Calle Clara, La Jolla, CA 92037 or by going to Class Counsel’s website at
www.bamlawca.com under “Class Notices” for Betorina v. Randstad. You may also get more details by examining
the Court’s file using PACER at http://www.cand.uscourts.gov/ and entering the Case No. 3:15-CV-03646.
PLEASE DO NOT CALL THE COURT ABOUT THIS NOTICE.
IMPORTANT:


You must inform the Settlement Administrator of any change of address to ensure receipt of your
settlement payment.



Settlement checks will be null and void 180 days after issuance if not deposited or cashed. In such
event, the Settlement Administrator shall direct all unclaimed funds to the California Department of
Industrial Relations Unclaimed Wages Fund with, if possible, an identification of the Class Member
who failed to cash the check. If your check is lost or misplaced, you should contact the Settlement
Administrator immediately to request a replacement.

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CLAIM FORM
(Betorina, et al. v. Randstad US, L.P., U.S. District Court,
Northern District of California Case No. 3:15-CV-03646 EMC)
INSTRUCTIONS: TO RECEIVE A SETTLEMENT PAYMENT YOU MUST
COMPLETE, SIGN AND MAIL THIS PROOF OF CLAIM FORM
THE CLAIM FORM MUST BE POSTMARKED ON OR BEFORE _______________,
2017 AND SENT TO: BETRINA v. RANDSTAD CLAIMS ADMINISTRATOR, C/O
______________________________, [mailing address].
CLAIMANT INFORMATION (If your name or address is different from those shown
below, print the corrections on the lines to the right.)
«Barcode» Claim #: SSEC1-«Claim»-«CD»- «MailRec»
Name / Mailing
Address Changes:
«FName» «LName»
_____________________________
«Addr1» «Addr2»
_____________________________
«City», «ST» «Zip»
_____________________________
«Social Security Number»
_____________________________
(

)
Area Code

_______________
Home Telephone Number

TO ALL PERSONS WHO WORKED FOR DEFENDANT RANDSTAD US, L.P. AS
SECURITY GUARDS WHO WERE PLACED OUT OF RANDSTAD BUSINESS UNIT
14023, AND CLASSIFIED AS NON-EXEMPT EMPLOYEES, FROM FEBRUARY 13,
2011 TO AUGUST 8, 2016 (“CLASS”):
A.

The records of Randstad US, L.P. (“Defendant”) show that you were employed as
a Class Member for a total of _____ workweeks during the period of February 13,
2011 to August 8, 2016 (“Class Period”).

B.

Based on this number of workweeks, your estimated Individual Settlement
Share is $____. This amount may vary depending on the total weeks claimed by
Class Members.

C.

In order to receive your share of the settlement, you must sign and return
this form to claim your portion of the settlement.

D.

Only if you dispute the number of weeks worked as reflected above, please write
the number you believe to be correct:
___________ weeks worked for Defendant in California as a Class Member
during the Class Period.
Please attach copies (not originals) of any supporting documents (pay stubs, etc.)
you have. The Claims Administrator may contact you for further information.
CLAIM FORM

RELEASED CLAIMS
As part of the Settlement, you will provide a full and complete release of all “Released Class
Claims” against Defendant, its current or former subsidiaries, affiliates, owners, parents,
predecessors, insurers, agents, employees, partners, successors, assigns, officers, officials,
directors, employers, attorneys, personal representatives, executors, and shareholders, including
their respective pension, profit sharing, savings, health, and other employee benefit plans of any
nature, the successors of such plans, and those plans’ respective current or former trustees and
administrators, agents, employees, and fiduciaries (“Releasees”).
“Released Class Claims” are defined as: any and all claims, rights, demands, charges, complaint,
causes of action, obligations or liability of any and every kind that were alleged in any version of
any complaint filed in the Action or in the Second Amended Complaint which occurred during
the Settlement Period, and expressly excluding all other claims, including claims for wrongful
termination, unemployment insurance, disability, workers’ compensation, and claims outside the
Settlement Period.
Release of FLSA Claims:
In addition to the claims enumerated above, by submitting this Claim Form, Qualified Claimants
will also release and forever waive any and all claims they may have under the Fair Labor
Standards Act (“FLSA”). This FLSA release only applies to claims through August 8, 2016, and
does not apply to future claims or claims after August 8, 2016. You do not have to opt in to the
FLSA Settlement. However, if you do not opt in by submitting this Claim Form, you will not
receive a settlement payment and you will still release the Released Class Claims as set forth
above.

TAXPAYER IDENTIFICATION NUMBER CERTIFICATION
Substitute IRS Form W-9
Enter the last four digits of your Social Security Number: XXX—XX–
I certify that:
1. The partial social security number shown on this form correctly states the last 4 digits of
my taxpayer identification number, 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. citizen or authorized to work in the United States of America.
Note: If you have been notified by the IRS that you are subject to backup withholding, you
must cross out item 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.
CLAIM FORM

I have not assigned any of my rights to any of the above Settlement Class Members’ Released
Claims.
I hereby confirm that the foregoing is true and correct.
FLSA OPT-IN
By signing below, I also hereby consent to join and opt-in to the FLSA Settlement. I
further certify that I understand and agree that by signing this FLSA Opt-In, I am agreeing to the
release of FLSA claims outlined in the Release of FLSA Claims above.
Dated: ____________

__________________________________________
Signature

CLAIM FORM