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Foxy Lady Claim

RUBY LEVI and EMILY CHICOINE, et al. v.
GULLIVER’S TAVERN, INCORPORATED and SOLID GOLD PROPERTIES, INC., d/b/a THE FOXY LADY

United States District Court for the District of Rhode Island

Case No. 1:15-cv-00216-WES-PAS

Claim Form & Release

To receive a settlement payment, you must complete this claim form and accompanying tax form.

First Name:

Last Name:

Street:

Apt/Unit:

City / Town:

State: Zip Code:

Phone:

Email:

What stage names did you use at the Foxy Lady?

What were the approximate dates that you worked as an entertainer at the Foxy Lady?

How many shifts per week did you generally work as an entertainer at the Foxy Lady?

I attest, under the penalties of perjury, that the information I have provided is true and accurate to the best of my knowledge. Also, by signing below and in consideration for my share of the settlement fund, I understand that am forever settling, compromising, releasing, discharging and dismissing all claims that were alleged or that could reasonably have been alleged in this lawsuit captioned Levi, et al. v. Gulliver’s Tavern, Incorporated, et al., Case No. 1:15-cv-00216-WES-PAS, against Gulliver’s Tavern, Incorporated, and Solid Gold Properties, as well as each of their former, existing, or future employees, supervisors, managers, officers, directors, owners, agents, and affiliates, under any of the laws, regulations, statutes, and common law of any state, including the State of Rhode Island, as well any federal, state, or local statute, ordinance, or regulation, including, without limitation, the Fair Labor Standards Act, 29 U.S.C. § 201, et seq., and Rhode Island General Laws § 28, et seq., that relate to or concern the defendants’ classification of entertainers at the Foxy Lady as independent contractors, payment of wages, hours worked, or gratuities.

Optime Administration, LLC – Substitute IRS Form W-9 & W4

Please print your Social Security Number (SSN): - -

Select One:

Single

Married

Married, but withhold at higher Single rate

Total number of allowances you are claiming:

Additional amount, if any, you want withheld from settlement payment:

Print your name as shown on your tax return:

Certification:

Under penalty of perjury, I certify that:

The social security number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and
I am a U.S. person (including a U.S. resident alien)

Signed Date:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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November 27, 2021 2:38 pm EDT

Foxy Lady Claim Uploaded by Optime Administration, LLC - [email protected] IP 73.114.220.204