CLAIM FORM

Re: Montoya, Carolina vs. Eatramen Holdings, LLC, Mecha Management Company, LLC., Tony Pham, and Richard Reyes, Case No. 2484CV01551

To claim a share of the settlement, you must FILL OUT, SIGN, all portions of this form.

IMPORTANT: This COMPLETED and SIGNED form must be received by JUNE 30, 2026.

ACKNOWLEDGEMENT & RELEASE

I have read and am familiar with the Notice of Settlement of Class Action Lawsuits to which this Claim Form relates. I understand that I am forever releasing and discharging Defendants and the Releasees from any and all wage and hours claims that could have been asserted in the lawsuit for the time period between June 21, 2021 and March 13, 2026, including but not limited to all claims for failure to pay tips under the Massachusetts Tips Act, M.G.L. c. 149, § 152A, and all claims for failure to pay the minimum wage under the Massachusetts Minimum Fair Wage Law, M.G.L. c. 151, §§ 1 and 7, and all claims for failure to timely pay wages under the Massachusetts Wage Act, M.G.L. c. 149, § 148, to the fullest extent permitted by law.

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.

Personal Information:

First Name:  

Last Name:  

Street Address:

Apt/Unit:

City:

State:

Zip Code:

Home or Mobile Phone:

E-mail:  

 Dated Signed:

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

Settlement distributions are considered taxable income and we are required to issue you a tax form. In order to generate a tax form, we need to have your social security number on file.

Please print your Social Security Number (SSN):

 -- 

Print your name as shown on your tax return:  

Certification:

Under penalty of perjury, I certify that:

1. 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
2. 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
3. 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.