CLAIM FORM

AURA SALAZAR, et al. v. FULFILLMENT AMERICA, INC., et al.

U.S. District Court for the District of Massachusetts, No. 23-11625

To claim a share of the settlement proceeds from this lawsuit, you must FILL OUT and SIGN this form. Once we receive your claim form, we will follow up to get additional information required to issue payment.

IMPORTANT: This COMPLETED and SIGNED form must be submitted by May 8, 2026.

NAME:  

ADDRESS:  

UNIT/APT:  

CITY:  

STATE:  

ZIP:  

PHONE:  

E-MAIL:  

DEPARTMENT AT FULFILLMENT AMERICA:  

I certify that the information above is accurate and that I worked at Fulfillment America, through Job Done, LLC, in December 2022.

Date Signed: