PLEASE SIGN BELOW AND RETURN FORM TO CLAIMS Sample Clauses

PLEASE SIGN BELOW AND RETURN FORM TO CLAIMS. ADMINISTRATOR In order to receive a payment from the Settlement, you must complete all of the information below and return this form and the W-4 Form to the Claims Administrator no later than [INSERT DATE 60 DAYS FROM NOTICE MAILING]. By signing below, you agree to the Release on pages 3-4 of this Consent to Join Settlement Form. If you have any questions about completing this Consent to Join Settlement Form, please call the Claims Administrator at ( ) . You may also contact Class Counsel at (000) 000-0000 or XXXxxxxxxxxxx@xxxxxxxxxxxx.xxx . (Print First and Last Name) (Beginning and End Date of Internship)× × Please provide the requested information to the best of your recollection. If you cannot remember, you can still receive a payment. (Social Security Number) (Name of Business Unit/Show You Interned With)× (Street Address) (Name During Internship – If Different From Above) (City, State, Zip Code) (Phone number)
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