Claim Form Superior Court Of The State Of California (Page 2 of 2) in pdf

of pay periods and/or work days during the applicable portion of the Class Period. The Claims Administrator will then make

a determination on your dispute based on your employment records and any other documents you submit. In resolving a

dispute, Golden Living’s records shall be presumed to be accurate and correct unless the information you submit proves

otherwise.

RELEASE OF CLAIMS

By signing this Claim Form and in exchange for the payment described above, you agree to the following release:

I release any and all claims, from June 8, 2008, through the date of the Preliminary Approval Order, against Released Parties

that were raised or that could have been raised under Federal or California law based upon the facts set forth in the

Complaints including, but not limited to, any known or unknown claims relating to allegations that Golden Living failed to

pay all overtime due, that Golden Living failed to provide all required meal periods and/or rest breaks, that Golden Living

failed to pay me all wages upon termination from employment, that Golden Living did not include all required accurate

information on my wage statements, and that Golden Living owes associated compensation and/or penalties, as founded on

state law (the “Released Claims”). The Released Claims include all such claims for wages and for civil or statutory penalties,

including but not limited to claims under the Fair Labor Standards Act, California Labor Code sections 201, 202, 203, 226,

226.7, 510, 512, 1174, 1174.5, 1194, 1194.2, 1198, claims for penalties under the Private Attorneys’ General Act (“PAGA”)

(Cal. Labor Code sec. 2699, et. seq.); claims of unfair competition under Cal. Business and Professions Code sec. 17200,

et. seq.; and costs and attorneys’ fees and expenses relating to the Released Claims.

I release all such claims, whether known or unknown by me, that fall within the scope of the Released Claims. Thus,

even if I discover facts and/or claims in addition to or different from those that I now know or believe to be true with

respect to the subject matter of the Released Claims, those claims will remain released and forever barred. Therefore,

with respect to those Released Claims, I expressly waive and relinquish the provisions, rights and benefits of section

1542 of the California Civil Code, which reads: “A general release does not extend to claims which the creditor does

not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her

must have materially affected his or her settlement with the debtor.”

SIGNATURE AND CERTIFICATION:

I have received and read the Notice of Proposed Class Action Settlement. I have had the

opportunity to consult with the attorneys of my choosing to ask questions about this lawsuit. I understand that I am releasing

any and all claims I might have against Golden Living that are alleged in or related to the Veurink action.

I wish to receive my share of the proposed Settlement in accordance with the terms of the

Settlement.

The last four (4) digits of my Social Security Number (SSN) are: __ __ __ __.

I declare under penalty of perjury under the laws of the State of California and the United States that the

foregoing three paragraphs are true and correct.

______________________, 2016.

Date

__________________________________________

Signature

___________________________________________

Typed or Printed Name

ILYM ID:

Claim Form Superior Court Of The State Of California Page 2