WP E-Signature by Approve Me - Sign Documents Using WordPress -

Rise Claim

CLAIM FORM & RELEASE

In order to participate in the settlement that is described in the Notice and claim a share of the settlement’s proceeds, you must complete, sign and submit this claim form

DEADLINE: Your completed Claim Form & Release and tax information must be received by no later than September 5, 2025.

DO NOT ALTER THE LANGUAGE BELOW. If you alter this language, your claim form will not be valid and will not be accepted.

Release of Claims:

In consideration for my receipt of a share of settlement funds, I am releasing Thielsch Engineering, Inc. d/b/a RISE Engineering and Brian Kearney, along with their respective parents, subsidiaries, affiliates, predecessors, successors, owners, directors, officers, members, employees, attorneys, representatives, heirs, and agents, as applicable to each of them, from all claims for overtime wages arising from the beginning of time to May 7, 2025, whether known or unknown, contingent or absolute, that were or could have been raised in the Lawsuit, including but not limited to claims under M.G.L. c. 151 and the Fair Labor Standards Act, 29 U.S.C. § 201, et seq., or any other statutory or common law overtime claims under federal, state, or local law.

Personal Information:

First Name:

Last Name:

Street Address:

Unit/Apt:

City:

State:

Zip Code:

Phone:

E-mail:

By signing below, I declare and verify that I have read this Claim Form, and that I agree to participate in the Settlement on the terms described herein, including the Release of Claims set forth above.

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)

Date Signed:

Note: If you have been notified by the IRS that you are subject to backup withholding, you must cross out line 2 above. The IRS does not require your consent to any provision of this document other than this Form W-9 certification to avoid backup withholding.

Signed Date:

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

July 11, 2025 9:25 am EST

Rise Claim Uploaded by Optime Administration, LLC - rise@optimeadmin.com IP 66.30.171.217