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Palace Pizza Claim

CLAIM FORM

Re: Anthony Archer v. T.A.G. and More Enterprises, Inc. (“Palace Pizza”)., et al.

Bristol Superior Court, Civil Action No. 2173-CV-00854-A

To claim a share of the settlement, you must FILL OUT, SIGN, and all portions of this form.

IMPORTANT: This COMPLETED and SIGNED form must be received by May 13, 2024.

First Name:

Last Name:

Address:

Apt/Unit:

City:

State:

Zip:

Phone:

Email:

ACKNOWLEDGEMENT & RELEASE

I have read and am familiar with the Notice of Settlement of Class Action Lawsuits to which this Claim Form relates. I understand that I will forever release and discharge Defendants (and their heirs, next of kin, executors, administrators, agents, representatives, insurers, attorneys, and assigns) of any claims that were or could have been asserted in the Action by Plaintiff (as an individual or Class Representative) relating to the payment of delivery charges and the payment of mileage reimbursement, going back six (6) years from the filing of the initial complaint in this Action through January 11, 2024.

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:

Print Name:

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Your legal name

Your email address

Please Confirm full name and signature.

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March 29, 2024 3:04 pm EST

Palace Pizza Claim Uploaded by Palace Pizza Settlement - [email protected] IP 73.114.220.204