proof of claim form for supplemental benefit

ROMAN et al. V. ADVANCED TECH SECURITY SERVICES

Los Angeles County Superior Court Case No. BC348282

TO RECEIVE A SUPPLEMENTAL BENEFIT PAYMENT YOU MUST COMPLETE, SIGN, AND MAIL THIS CLAIM FORM BY FIRST CLASS U.S. MAIL OR EQUIVALENT, POSTAGE PAID, POSTMARKED ON OR BEFORE _______________ ____, 2009 or your claim will be rejected.

1. You must complete, sign and mail this Claim Form to be eligible to receive a Supplemental Benefit settlement payment.

2. If you move, please send the Claims Administrator your new address. It is your responsibility to keep a current address on file with the Claims Administrator.

3.         If you have questions, please write to the Claims Administrator at the address shown below.

COMPLETE, SIGN AND MAIL TO:         

                                                                        Roman v. Advanced Tech Security Services Inc.

                                                                        Claims Administration

                                                                        c/o Desmond, Marcello & Amster

6060 Center Drive, Suite 825

Los Angeles, California  90045

MUST BE POSTMARKED NO LATER THAN  December             , 2009

1.            Advanced Tech Security Services, Inc., now known as Andrews International, Inc.’s company records indicate that you were employed by the company sometime during the period March 2, 2002 through December 31, 2003 as a security officer employee or other job(s) related to non-exempt security work.

2.            If you in fact were employed by Advanced Tech Security Services, Inc. / Andrews International Inc.  („Andrews“ ) during the time period indicated, whether or not you are currently employed by Andrews, and regularly  worked  shifts of  ten (10) hours or longer at posts where you were required to take your meal break on duty and/or did not receive a second meal break, please complete the following. If you were not employed by Andrews during the time period, or believe you received all appropriate meal breaks, there is no need to respond.

CLAIM INFORMATION

Make any address corrections here:            

<Name>                                                _________________________________________

<Address>                                    _________________________________________

<City, State, Zip>                         _________________________________________

Social Security Number:             ___ ___ ___-___ ___ -___ ___ ___ ___

Telephone Number:             (Work) (___ ___ ___) ___ ___ ___-___ ___ _

Telephone Number:             (Home) (___ ___ ___) ___ ___ ___-___ ___ _

            To the best of my recollection, the following represents the dates and/or number of shifts I worked for Advanced Tech Security Services, Inc. / Andrews International, Inc. On shifts of ten hours or longer when I did not receive a second meal break are: