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FILED: NEW YORK COUNTY CLERK 02/27/2023 09:07 AM INDEX NO. 160513/2018
NYSCEF DOC. NO. 80 RECEIVED NYSCEF: 02/27/2023
NY BOILER CLAIM FORM
YOU MUST COMPLETE THIS FORM IF YOU WISH TO RECEIVE A SETTLEMENT PAYMENT
CLAIM FORM INSTRUCTIONS
You are encouraged to read the Notice of Settlement of Class Action Lawsuit (the “Notice”), which accompanies
this CLAIM FORM. To be entitled to participate in this proposed Class Action settlement, you must mail, fax or e-
mail this claim form, and completed W-9 form on or before ________________, 2023 (the “Claim Bar Date”) to:
Settlement Claims Administrator
________________, NY
Tel: _________ Fax: ________________ E-Mail: info@__________.com
RE: NY BOILER Class Action
FAILURE TO FILE A FULLY COMPLETED CLAIM FORM AND THE ENCLOSED W-9 AND W-4 FORM
POST-MARKED, FAXED OR EMAILED BY ________, 2023 YOU MAY BE PROHIBITED FROM
RECEIVING A SETTLEMENT PAYMENT, UNLESS OTHERWISE PERMITTED BY THE COURT.
THE INFORMATION PROVIDED ON THE CLAIM FORM, W-9 and W-4 FORMS IS STRICTLY
CONFIDENTIAL AND WILL ONLY BE USED TO PREPARE YOUR SETTLEMENT CHECK.
This Claim Form must be accompanied by completed and signed W-4 and W-9 forms. You must include your social
security number (“SSN”) or tax identification number (“TIN”) on the forms. If you do not have an SSN or TIN, you
will still be allowed to receive a settlement payment; however, you will have until _____________ 2023 to obtain a
TIN or SSN, provided your Claim Form is submitted timely, otherwise your settlement money will be returned to NY
Boiler and you will not receive a payment.
IF YOU HAVE ANY QUESTIONS AND WISH TO SPEAK WITH AN ATTORNEY PLEASE CONTACT
VIRGINIA & AMBINDER AT 212 943 9080. COMMUNICATIONS WITH VIRGINIA & AMBINDER
WILL BE STRICTLY CONFIDENTIAL
THIS CLAIM FORM AND THE ENCLOSED W-4 AND W-9 FORMS MUST BE FAXED, EMAILED OR
MAILED AND POST-MARKED ON OR BEFORE ____________, 2023
________________________________________________________________________________________________
(First, Middle, Last)
________________________________________________________________________________________________
(Street Address)
________________________________________________________________________________________________
(City) (State) (Zip Code)
________________________________________________________________________________________________
Email (PRINT NEATLY) Telephone Number
By signing this Claim Form, I consent to participate in this settlement against New York Boiler, Inc., Richard Berger and
Donald Berger for alleged unpaid wages including prevailing wages and benefits, spread of hours compensation, expense
reimbursement, and liquidated damages. I hereby release New York Boiler, Inc. and any of its present and former parent
companies, subsidiaries, related or affiliated entities as well as Richard Berger and Donald Berger and any respective
shareholders, officers, directors, employees, members, managers, fiduciaries, trustees, employee benefit plan
administrators (except only as to any previously vested entitlements), agents, attorneys, insurers, successors and assigns,
as well as all persons or entities acting by, through, under or in concert with any of them (collectively, “Releasees”),
from all wage and hour claims under the federal Fair Labor Standards Act, the New York Labor Law, the Davis Bacon
FILED: NEW YORK COUNTY CLERK 02/27/2023 09:07 AM INDEX NO. 160513/2018
NYSCEF DOC. NO. 80 RECEIVED NYSCEF: 02/27/2023
Act, the Service Contract Act, U.S. Housing Act of 1937, the New York City Administrative Code, the New York Code of
Rules and Regulations, and all claims for breach of any contract claims (including third-party beneficiary claims), for
minimum wages, unpaid wages, overtime wages, spread of hours compensation, employee benefits, and including without
limitation all liquidated damages, interest, attorneys’ fees, costs and expenses, Settlement Claims Administrator’s fees
and costs, Service Award, and damages, and any and all other claims which have been brought or could have been
brought in the Litigation or that are based on the same facts and circumstances as the claims in the Litigation from
November 13, 2012 through and including the Effective Date and expressly release any such claims. I represent and
warrant that I have not assigned or transferred, or purported to assign or transfer, to any person or entity, any claim or
any portion thereof or interest therein, including, but not limited to, any interest in the Litigation, or any related action.
I further understand that nothing in this release or my participation in this settlement shall in any way release or relinquish
claims I may possess under the worker compensation law, for unemployment benefits, or arising in tort for personal
injury. I further understand that this release shall be strictly limited to claims arising out of and in connection with my
employment with Releasees from November 13, 2012 through and including the Effective Date
SIGNATURE:_______________________________________________________
4881-3180-4745, v. 1
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FILED: NEW YORK COUNTY CLERK 02/27/2023 09:07 AM INDEX NO. 160513/2018 NYSCEF DOC. NO. 80 RECEIVED NYSCEF: 02/27/2023 NY BOILER CLAIM FORM YOU MUST COMPLETE THIS FORM IF YOU WISH TO RECEIVE A SETTLEMENT PAYMENT CLAIM FORM INSTRUCTIONS You are encouraged to read the Notice of Settlement of Class Action Lawsuit (the “Notice”), which accompanies this CLAIM FORM. To be entitled to participate in this proposed Class Action settlement, you must mail, fax or e- mail this claim form, and completed W-9 form on or before ________________, 2023 (the “Claim Bar Date”) to: Settlement Claims Administrator ________________, NY Tel: _________ Fax: ________________ E-Mail: info@__________.com RE: NY BOILER Class Action FAILURE TO FILE A FULLY COMPLETED CLAIM FORM AND THE ENCLOSED W-9 AND W-4 FORM POST-MARKED, FAXED OR EMAILED BY ________, 2023 YOU MAY BE PROHIBITED FROM RECEIVING A SETTLEMENT PAYMENT, UNLESS OTHERWISE PERMITTED BY THE COURT. THE INFORMATION PROVIDED ON THE CLAIM FORM, W-9 and W-4 FORMS IS STRICTLY CONFIDENTIAL AND WILL ONLY BE USED TO PREPARE YOUR SETTLEMENT CHECK. This Claim Form must be accompanied by completed and signed W-4 and W-9 forms. You must include your social security number (“SSN”) or tax identification number (“TIN”) on the forms. If you do not have an SSN or TIN, you will still be allowed to receive a settlement payment; however, you will have until _____________ 2023 to obtain a TIN or SSN, provided your Claim Form is submitted timely, otherwise your settlement money will be returned to NY Boiler and you will not receive a payment. IF YOU HAVE ANY QUESTIONS AND WISH TO SPEAK WITH AN ATTORNEY PLEASE CONTACT VIRGINIA & AMBINDER AT 212 943 9080. COMMUNICATIONS WITH VIRGINIA & AMBINDER WILL BE STRICTLY CONFIDENTIAL THIS CLAIM FORM AND THE ENCLOSED W-4 AND W-9 FORMS MUST BE FAXED, EMAILED OR MAILED AND POST-MARKED ON OR BEFORE ____________, 2023 ________________________________________________________________________________________________ (First, Middle, Last) ________________________________________________________________________________________________ (Street Address) ________________________________________________________________________________________________ (City) (State) (Zip Code) ________________________________________________________________________________________________ Email (PRINT NEATLY) Telephone Number By signing this Claim Form, I consent to participate in this settlement against New York Boiler, Inc., Richard Berger and Donald Berger for alleged unpaid wages including prevailing wages and benefits, spread of hours compensation, expense reimbursement, and liquidated damages. I hereby release New York Boiler, Inc. and any of its present and former parent companies, subsidiaries, related or affiliated entities as well as Richard Berger and Donald Berger and any respective shareholders, officers, directors, employees, members, managers, fiduciaries, trustees, employee benefit plan administrators (except only as to any previously vested entitlements), agents, attorneys, insurers, successors and assigns, as well as all persons or entities acting by, through, under or in concert with any of them (collectively, “Releasees”), from all wage and hour claims under the federal Fair Labor Standards Act, the New York Labor Law, the Davis Bacon FILED: NEW YORK COUNTY CLERK 02/27/2023 09:07 AM INDEX NO. 160513/2018 NYSCEF DOC. NO. 80 RECEIVED NYSCEF: 02/27/2023 Act, the Service Contract Act, U.S. Housing Act of 1937, the New York City Administrative Code, the New York Code of Rules and Regulations, and all claims for breach of any contract claims (including third-party beneficiary claims), for minimum wages, unpaid wages, overtime wages, spread of hours compensation, employee benefits, and including without limitation all liquidated damages, interest, attorneys’ fees, costs and expenses, Settlement Claims Administrator’s fees and costs, Service Award, and damages, and any and all other claims which have been brought or could have been brought in the Litigation or that are based on the same facts and circumstances as the claims in the Litigation from November 13, 2012 through and including the Effective Date and expressly release any such claims. I represent and warrant that I have not assigned or transferred, or purported to assign or transfer, to any person or entity, any claim or any portion thereof or interest therein, including, but not limited to, any interest in the Litigation, or any related action. I further understand that nothing in this release or my participation in this settlement shall in any way release or relinquish claims I may possess under the worker compensation law, for unemployment benefits, or arising in tort for personal injury. I further understand that this release shall be strictly limited to claims arising out of and in connection with my employment with Releasees from November 13, 2012 through and including the Effective Date SIGNATURE:_______________________________________________________ 4881-3180-4745, v. 1