Claim Form Superior Court Of The State Of California printable pdf download

CLAIM FORM

SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF SONOMA

LESLIE VEURINK. V. BEVERLY HEALTH AND REHABILITATION SERVICES, INC., ET AL.

CASE NO. SCV-255496

YOU MUST TIMELY COMPLETE, SIGN AND RETURN THIS FORM BY MAY 2, 2016 TO BE ELIGIBLE FOR

A MONETARY RECOVERY.

<<Name>>

____________________________________

<<Address Line 1>>

____________________________________

<<Address Line 2>>

____________________________________

<<City, State>>

____________________________________

<<Telephone Number>>

____________________________________

If your name or address is different from those shown above, print the corrections on the lines to the right. If you move,

please send us your new address.

YOU MUST COMPLETE, SIGN AND MAIL THIS FORM BY FIRST CLASS U.S. MAIL OR EQUIVALENT,

POSTAGE PAID, POSTMARKED ON OR BEFORE MAY 2, 2016 ADDRESSED AS FOLLOWS TO BE ELIGIBLE

TO RECEIVE A RECOVERY.

ILYM Group, Inc.

P.O. Box 130

Tustin, CA 92781

Under the terms of this Settlement, you qualify to claim an estimated pre-tax payment of approximately $<<estimated

award>>. This is the estimated gross amount that you will receive if you timely submit this claim form subject to the

following. Your actual gross settlement payment may end up being higher than estimated, depending on the number of

Class Members who actually file claims and whether the Court approves the costs of the lawsuit as described in the Notice

of Proposed Class Action Settlement (“Class Notice”) you received with this Claim Form. In any event, your gross

settlement payment will be subject to appropriate withholding for both the employee and employer portion of applicable

payroll taxes relating to the wage portion of the settlement payment.

Your gross settlement payment is based on your employment with Beverly Health and Rehabilitation Services, Inc., GGNSC

Administrative Services, LLC, and/or Hospice Preferred Choice, Inc. (“Golden Living”) during all or some of the period

from June 8, 2008 through May 23, 2014 (the “Class Period”). As explained in detail in the enclosed Class Notice, Golden

Living’s payroll records indicate you are entitled to participate and receive a settlement payment as a member of the

following Settlement Class:

All current and former clinical employees of Beverly Health and Rehabilitation Services, Inc., GGNSC

Administrative Services, LLC and Hospice Preferred Choice, Inc., (“Golden Living”) employed in

California during the Class Period, i.e. from June 8, 2008 to May 23, 2014. The certified class specifically

excludes: 1) any individual who is a Plaintiff in pending litigation against Golden Living in federal or state

court involving claims under the FLSA or California Labor Code or who executed a court-approved waiver

of claims in any such case, and 2) any individual who chose to opt-in and receive a settlement payment in

the case of Jarrett v. GGNSC Holdings, LLC, 2:12-cv-04105 BP, pending in the United States District Court

for the Western District of Missouri.

As a member of this Settlement Class, Golden Living’s payroll records indicate you worked [insert total pay periods]

during the period of [insert dates of employment during class period]. Your approximate gross pre-tax payment as part of

the Settlement Class is [insert approximate payment]. This payment will be characterized as 50% wages and 50% interest

and penalties. Your share of payroll and income taxes, and all other applicable deductions or withholding required by law

or expressly authorized by you, including payments of any liens, garnishments or levies, shall be withheld from the

settlement payment.

If you disagree with the number of periods and/or work days listed above, you may dispute these numbers by submitting

satisfactory documentation to the Claims Administrator with this Claim Form showing that you worked a different number

ILYM ID:

Claim Form Superior Court Of The State Of California

Related Articles

Related forms

Related Categories