ATKINSON CLAIM FORM
I acknowledge that as a Settlement Class Member entitled to receive a pro rata share of the Net Settlement Funds in this matter, I am releasing Atkinson Concessions, Inc. from any and all legal claims that I may have, whether known or unknown, contingent or absolute, that were or could have been asserted in Constanza Kiran, on behalf of herself and others similarly situated v. Atkinson Concessions, Inc., Rockingham Superior Court. Civil Action No. 218-2021-CV-01175. The claims that I am releasing include any claims concerning improper distribution of tips, gratuities, and/or service charges, or maintenance of an unlawful tip pool, at the Atkinson Resort and Country Club from November 22, 2018, through October 2, 2022.
IMPORTANT: This COMPLETED and SIGNED form must be received by APRIL 10, 2023.
Please print your Social Security Number (SSN):
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:
Under penalty of perjury, I certify that:
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.
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Signed by Optime Administration, LLC
Signed On: February 27, 2023
If you have questions about the contents of this document, you can email the document owner.
Document Name: Atkinson Claim
Agree & Sign