Pontones v. San Jose Restaurant, Incorporated, et al.

Case No. 5:18-CV-219-D

U.S. District Court, Eastern District of North Carolina

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CLAIM FORM AND CONSENT TO JOIN

In order to receive a payment under the Settlement Agreement, please complete and timely submit this Claim Form to the Settlement Administrator. To be considered timely, this form must be submitted by no later than June 17, 2022.

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I, hereby opt into this settlement pursuant to Section 216(b) of the Fair Labor Standards Act, 29 U.S.C. §§ 201, et seq. (“FLSA”), authorize Class Counsel to represent me in this Settlement, and agree to waive and release any and all claims under the federal Fair Labor Standards Act (“FLSA”), North Carolina Wage and Hour Act (“NCWHA”), and any other wage-related claims, laws, and regulations, from the start of my employment with San Jose Restaurants (“San Jose”) through the Effective Date of the settlement, including, but not limited to, claims for back pay, liquidated damages, penalties, interest, and attorneys' fees, costs, and expenses. Further:

  • I wish to participate in the parties’ proposed settlement if approved by the Court.
  • I understand that if the settlement is approved by the Court, I will receive a check totaling approximately before taxes.
  • I understand that I must keep the Settlement Administrator informed of any change in my address. If I do not do so, I understand that I may not receive any settlement payment that I might otherwise be entitled to receive.

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CLAIM INFORMATION
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