Preview
FILED: NEW YORK COUNTY CLERK 03/13/2023 03:03 PM INDEX NO. 160513/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 03/13/2023
TO BE PUBLISHED IN ENGLISH AND SPANISH
Portuguese, Russian and Polish Translation Available Upon Request.
Please Refer To Notice At Question 2 For Class Counsel Contact Information
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, on or before [bar date] you must
return this Claim Form, W-9 and W-4 forms to the Settlement Class Administrator by mail, email, fax, or by accessing
the Settlement Claims Administrator’s web page to access a fillable pdf Claim Form, Objection Statement or Opt-out
Form that will automatically be filed upon completion.
Settlement Claims Administrator
________________, NY
Tel: _________ Fax: ________________ E-Mail: info@__________.com
Website Address:______________________
RE: NYB 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 IN THE ENCLOSED SELF ADDRESSED STAMPED ENVELOPE TO THE SETTLEMENT
CLAIMS ADMINISTRATOR ON OR BEFORE ____________, 2023.
YOU MAY ALSO ACCESS ELECTRONIC VERSIONS OF THESE FORMS, AS WELL AS AN OPT-
OUT FORM AND OBJECTION FORM ON THE SETTLEMENT CLAIMS ADMINITRATOR’S WEB
PAGE: [________________]
________________________________________________________________________________________________
(First, Middle, Last)
________________________________________________________________________________________________
FILED: NEW YORK COUNTY CLERK 03/13/2023 03:03 PM INDEX NO. 160513/2018
NYSCEF DOC. NO. 90 RECEIVED NYSCEF: 03/13/2023
(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
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