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Atkinson Claim

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.

First Name:

Last Name:

Address:

Unit/Apt:

City:

State: Zip:

Phone:

Email:

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.

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Signed by Optime Administration, LLC
Signed On: February 27, 2023

Timestamp

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February 23, 2023 9:40 am EST

Atkinson Claim Uploaded by Optime Administration, LLC - [email protected] IP 73.114.220.204, 132.148.110.13, 0.0.0.0, 73.114.220.204