Class Action Settlement Claim Form (Page 2 of 2) in pdf

Class Action Settlement Claim Form Page 2

PRINT your name:

____________________________________________________________

Other/maiden name: ____________________________________________________________

Street Address:

____________________________________________________________

Apt./Suite No.:

____________________________________________________________

City:

__________________________State:_________Zip Code:____________

Social Security No.: ____________________________________________________________

Your Telephone No.: ____________________________________________________________

I understand that this Claim Form is being submitted under the terms of the proposed settlement

described in the NOTICE OF PRELIMINARY APPROVAL OF CLASS ACTION

SETTLEMENT AND FURTHER NOTICE OF HEARING FOR FINAL APPROVAL OF

CLASS ACTION SETTLEMENT.

I submit to the jurisdiction of the San Diego County

Superior Court with respect to my claim as a Class Member and for the purposes of enforcing the

Release of Claims set forth in the Settlement Agreement. The full and precise terms of the

proposed Settlement are contained in the “Settlement Agreement” filed with the Court. I further

acknowledge that to the extent that I submit a Claim Form, I will be bound by and subject to the

terms of any judgment that may be entered in this class action.

Upon receipt of my share of the settlement proceeds, I hereby release 3 Weiss Guys, Inc. dba

Bourbon Street and/or Michael Weiss dba Lei Lounge, and their owner, affiliates, employees,

agents, and attorneys, from any and all claims and causes of action set forth in the Complaint on

file in this lawsuit.

Executed on: ___________________, 2010.

_______________________________________________

SIGNATURE OF CLAIMANT

Page 2 of 2

Class Action Settlement Claim Form Page 2