Notice to class

Notice to class
(long)

Claims Form

BLACKBURN V. BARRY’S SECURITY SERVICES, INC. CLAIM AND RELEASE FORM   Name:                   Address:             Daytime Telephone Number                              Evening Telephone Number                              TAXPAYER IDENTIFICATION NUMBER CERTIFICATION:   Substitute IRS Form W-9 Enter the last four digits of your Social Security Number (SSN): Print name as shown on your income tax return:     Certification Under penalty of perjury, I certify that: The Taxpayer identification number shown on this form is my correct taxpayer identification number, 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 interested or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, I am a U.S. person (including a U.S. resident alien). Please Check One:                 Yes                        No 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. RELEASE and CLAIMANT SIGNATURE: My Electronic Verification in the form of the last four digits of my social security number, or my signature constitutes a full and complete release by me of Barry’s Security Services, Inc., its present and former parent companies, subsidiaries, related or affiliated companies, general partners, limited partners, shareholders, officers, directors, employees, agents, attorneys, insurers, successors and assigns, and any individual or entity which could be jointly liable with Barry’s Security Services, Inc. for all claims alleged in Blackburn v. Barry’s Security Services, Inc. including all claims for violation of California Labor Code §§ 512 and 226.7 for Unpaid Meal and Rest Periods, claims for attorneys’ fees, costs, expenses, penalties, liquidated damages, punitive damages, or penalties under federal, state, and local law for employment in California, from January 1, 2003 through December 31, 2007. I declare under penalty of perjury under the laws of the State of California and the Untied States that the foregoing is true and correct. X   (Sign your name here) Date By entering the last four digits of my social security number, I certify that this Electronic Form is the same as an original signature, binding by law and demonstrates my express authorization of the terms of this Release and Claim Form.                                                             Last Four Digits of Social Security Number (FOR ELECTRONIC SIGNATURE

 

 

 

 

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