IN THE MATTER OF GRIEVANCES BETWEEN:

AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES (AFGE) LOCAL 3313 Union

v. UNITED STATES DEPARTMENT OF TRANSPORTATION

Agency

PROOF OF CLAIM

DEADLINE FOR SUBMISSION: Eligible Bargaining Unit Employees Must Submit This Proof Of Claim By Online Electronic Submission Or Mailed Postmarked On Or Before September 23, 2019.

Part 1: Claimant Identification

Claimant/Authorized Executor/Administrator Contact Information: The Claims Administrator will use the contact information for all correspondence relevant to this claim. If the contact information changes, then you must notify the Claims Administrator in writing at the above address

Claimant’s LAST NAME

Claimant’s FIRST NAME MI

Address

City State Zip

Foreign Province & Postal Code Foreign Country

Social Security Number

Telephone Number (Cell) Telephone Number (Home/Work/Other)

Email

NAME (Authorized Executor/Administrator, if applicable)

Last First MI

Taxpayer Identification Number

-

Part 2: ELIGIBILITY CRITERIA FOR A COVERED BARGAINING UNIT EMPLOYEE TO PARTICIPATE IN THE SETTLEMENT FUND DISTRIBUTION

A. Grievance Settlement Fund Distribution Timeframes

I was: (Please check the box that applies to you)

⃞ 1. An employee who held a bargaining unit position in the Federal Motor Carrier Safety Administration

(FMCSA), the National Highway Traffic Safety Administration (NHTSA), the Federal Transit Administration (FTA), and the Office of the Secretary of Transportation (OST) (non-professionals, only) at any time during the Grievance timeframe from July 30, 2012 through October 4, 2018; or

⃞ 2. An employee who held a bargaining unit position in the Pipeline and Hazardous Materials Safety

Administration (PHMSA) at any time during the Grievance timeframe from May 5, 2013 through October 4, 2018; or

⃞ 3. An employee who held a bargaining unit position in the Bureau of Transportation Statistics (BTS),

Office of the Assistant Secretary for Research and Technology at any time during the Grievance timeframe from February 9, 2015 through October 4, 2018; or

⃞ 4. An employee who held a Professional bargaining unit position in the Office of the Assistant

Secretary for Transportation (OST) at any time during the Grievance timeframe from January 21, 2015 through October 4, 2018; and

B. Proof of FLSA Overtime Grievance Lawsuit Participation

I was an employee who, during the Grievance Timeframes specified in Paragraph A, Sections 1 through 4 directly above: (Please check the box that applies to you)

⃞ 1. Participated in the FLSA Grievance Lawsuit by: a) submitting claims/damages information; or b)

filed an affidavit; or c) completed a survey; or d) completed a non-election form; or

⃞ 2. Previously opted out of the FLSA Grievance Lawsuit but later provided an affidavit in support of a

claim; or

⃞ 3. Did not want to participate in the FLSA Grievance Lawsuit but provided an affidavit in support of a

claim; and

4. An employee who was part of the bargaining unit for four (4) or more quarters between July 30,

2012 through October 4, 2018.

Part 3: Certification & Signature

By submitting this Proof of Claim, I certify that: (i) I am the individual or legal entity named above (if you are the individual’s or legal entity’s representative, please supply documentation supporting your authority to act on behalf of such individual or entity) and (ii) I provided all transaction information and documentation required.

⃞ I CERTIFY THAT I AM A FEDERAL EMPLOYEE UNDER CSRS (CIVIL SERVANT RETIREMENT SYSTEM) AND NOT

SUBJECT TO FICA WITHHOLDINGS.

⃞ I CERTIFY THAT I AM NOT SUBJECT TO BACKUP WITHHOLDING UNDER THE PROVISIONS OF SECTION

3406(A)(1)(C) OF THE INTERNAL REVENUE CODE.

Note: If you have been notified by the Internal Revenue Service that you are subject to backup withholding, please strike out the language that you are not subject to backup withholding in the certification above.

UNDER THE PENALTIES OF PERJURY, I CERTIFY THAT ALL OF THE INFORMATION PROVIDED ON THIS PROOF OF CLAIM FORM IS TRUE, CORRECT AND COMPLETE.

Executed this _____ day of _______________, in ________________________, __________________________

(Month/Year) (City) (State, Country)

Signature of Claimant

Print Claimant Name

Date

If Claimant is other than an individual, or is not the person completing this form, the following also must be provided:

Signature of Person Completing Form Date

Print Name of Person Completing Form Capacity of Person(s) Signing, (e.g., Authorized Executor/Administrator)

ACCURATE CLAIMS PROCESSING TAKES A SIGNIFICANT AMOUNT OF TIME! THANK YOU FOR YOUR PATIENCE!

REMINDER CHECKLIST

1. Please completely fill out, sign, date and submit the above Proof of Claim and Release Form, including all required supporting documentation (Proof of Claim, Form W-4, Form W-9, Payment Election & Consent Form).

2. If this claim is being made on behalf of a Claimant (Authorized Executor/Administrator), then attach all required documentation

3. Keep a copy of your Proof of Claim form and all documents submitted for your records.

4. If any of your contact information changes, then please update your information by contacting Claims Administrator,

AFGE Local 3313 Settlement c/o C. Brown Associates, Inc., 9646 Pennsylvania Avenue, Upper Marlboro, MD 20772, via email: claims@cbrownassoc.com or call (301) 577-7110.

5. If you have any questions about this Notice, the Settlement Fund, or the filing of a Proof of Claim, please direct your questions to the Claims Administrator via email claims@cbrownassoc.com or call (301) 577-7110.

Helpful Hints On-Line

6. Before you begin the on-line registration process, you must complete (print, fill in, sign, date & scan) the Proof of Claim, which you will later UPLOAD during the on-line registration process.

7. Select link to complete and submit required documentation by On-Line Electronic Submission - www.cbrownassoc.com/afge.html

8. Once you have registered on-line, you will be able to sign in at any time to update your information and check the status of your claim.

Mailing

9. If you are submitting your Proof of Claim by mail and you would like an acknowledgement of receipt, then please send it by Certified mail, Return Receipt Requested.

THIS FORM, INCLUDING ALL REQUIRED SUPPORTING DOCUMENTATION, MUST BE SUBMITTED BY ON-LINE ELECTRONIC SUBMISSION OR MAILED POSTMARKED ON OR BEFORE SEPTEMBER 23, 2019.