Claim Form For Massage Envy Franchising printable pdf download

CLAIM FORM

FOR MASSAGE ENVY FRANCHISING, LLC CLASS ACTION SETTLEMENT

US DISTRICT COURT, NORTHERN DISTRICT OF CALIFORNIA

CASE NO. 3-12-cv-06327-NC

Please type or print any changes below:

BARCODE

CLASS MEMBER NAME

ADDR1

ADDR2

CITY STATE ZIP

DATED: September 24, 2014

TO:

CLAIMANT NAME

GENERAL INSTRUCTIONS

Please read this carefully. You may be entitled to a Settlement payment in the above-named case.

This Claim Form relates to the Settlement of a class action lawsuit entitled Balderas v. Massage

Envy Franchising, LLC, et al., Case No. 3-12-cv-06327-NC, currently pending in the United Stated

District Court for the Northern District of California (the “Action”). You are receiving this notice

because you have been identified as a Massage Therapist at one or more California Massage Envy

clinics or spas (“California Franchises”) who may be entitled to receive a Settlement benefit if the

Settlement is approved by the Court.

This Claim Form must be postmarked no later than December 8, 2014, if you wish to make a claim.

For further information, see the Notice of Proposed Class Action Settlement sent with this Claim Form,

and/or the Settlement Agreement which is available at

Please print clearly using dark ink. Failure to complete this form may result in your claim being

delayed or denied. You will need to sign this Claim Form at the end of Section 2 to certify under

penalty of perjury that the information you provide is true to the best of your knowledge. Please be aware

that Claim Forms may be verified to confirm the accuracy of any statements made. Claim Forms that

are not signed will be considered invalid, and will prevent you from receiving payment.

Mailing Instructions. Mail this completed Claim Form to the Settlement Administrator, MT Business

Expense Settlement Administrator, postmarked on or before December 8, 2014, at the following

address:

MT Business Expense Settlement Administrator

P.O. Box 3614

Minneapolis, MN 55403-0614

1-888-755-9508

Questions. Please note that there is additional information available at the Settlement Website which is

available at You may also contact MT Business Expense

Settlement Administrator at the above-referenced address or telephone number, or Class Counsel at:

Monique Olivier, Esq.

Duckworth Peters Lebowitz Olivier LLP

100 Bush Street, Suite 1800

San Francisco, CA 94104

Tel: (415) 433-0333 x 6

Claim Form For Massage Envy Franchising