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Claim Form

Claimant Information

First Name

Last Name

Other names used in the past

SSN/TIN

Note: The SSN/TIN will be used to calculate how much tax will be withheld from settlement checks. If left blank, the full amount of taxes required by law will be withheld from your settlement check, if your claim is deemed eligible.

Address 1

Address 2

City

State

ZIP Code

Phone

Email

Employment Details

Please provide the Names of Labor Contractors you worked for when making deliveries for Home Express Delivery Service, LLC doing business as Temco Logistics from April 17, 2019, to November 21, 2023, as well as the date(s) you started and stopped work. You must provide details on at least one Labor Contractor to submit this Claim Form.

Note: If you were a delivery driver or helper for multiple Labor Contractors, please provide the required details for each Labor Contractor.

Labor Contractor Name	Start Date of Employment	End Date of Employment

Attestation & Signature

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Signature

Date