Los Angeles local civil form — [model] Class Action and Paga Settlement Agreement and Class Notice (LASC CIV 296)

Source: https://lascpubstorage.blob.core.windows.net/forms/Forms%20Comprehensive%20List/LASC%20CIV%20296.pdf

[NOTE: This Model Class Action and PAGA Settlement Agreement is based on a version originally approved by the Court, the complex litigation judges, and a 2022 Ad Hoc Wage and Hour Committee co-chaired by Judge David Cunningham and Judge Amy Hogue (Ret.) and including 16 attorneys who regularly represent plaintiffs and defendants in wage and hour cases. It is written for settlements of single plaintiff wage and hour actions asserting class claims and PAGA claims against a single employer (XYZ). The parties will need to revise this form for multiple plaintiffs or multiple defendants. For settlements of wage and hour class actions that do not include PAGA claims, please use the Model Class Action Settlement Agreement and Class Notice. COUNSEL USING THIS MODEL AGREEMENT ARE TO ATTACH A REDLINED VERSION TO THEIR MOTIONS FOR APPROVAL SHOWING HOW THE PARTIES HAVE MODIFIED THIS MODEL AGREEMENT.]

[MODEL] CLASS ACTION AND PAGA SETTLEMENT AGREEMENT AND CLASS NOTICE

This Class Action and PAGA Settlement Agreement (“Agreement”) is made by and

between plaintiff (“Plaintiff”) and defendant (“XYZ”). The Agreement refers to Plaintiff and XYZ collectively as “Parties,” or individually as “Party.”

1. DEFINITIONS.

   1.1 “Action” means the Plaintiff’s lawsuit alleging wage and hour violations against XYZ captioned initiated on and pending in the Court.

   1.2 “Administrator” means , the neutral entity the Parties have agreed to appoint to administer the Settlement.

   1.3 “Administration Expenses Payment” means the amount the Administrator will be paid from the Gross Settlement Amount to reimburse its reasonable fees and expenses in accordance with the Administrator’s “not to exceed” bid submitted to the Court in connection with Preliminary Approval of the Settlement.

   1.4 “Aggrieved Employee” means [e.g., a person employed by XYZ in California and classified as a who worked for XYZ during the PAGA Period].

   1.5 “Class” means [define class, e.g., all persons employed by XYZ in California and classified as who worked for XYZ during the Class Period].

   1.6 “Class Counsel” means .

   1.7 “Class Counsel Fees Payment” and “Class Counsel Litigation Expenses Payment” mean the amounts allocated to Class Counsel for reimbursement of reasonable attorneys’ fees and expenses, respectively, incurred to prosecute the Action. 1

SCLAC CIV 296 Rev. 04/26 For Optional Use

1.8 “Class Data” means Class Member identifying information in XYZ’s possession including the Class Member’s name, last-known mailing address, Social Security number, and number of Class Period Workweeks and PAGA Pay Periods.

1.9 “Class Member” or “Settlement Class Member” means a member of the Class, as
either a Participating Class Member or Non-Participating Class Member (including a
Non- Participating Class Member who qualifies as an Aggrieved Employee).

1.10 “Address Search” means the Administrator’s investigation and search for current Class Member or Aggrieved Employee mailing addresses using all reasonably available sources, methods and means including, but not limited to, the National Change of Address database, skip traces, and direct contact by the Administrator with Class Members or Aggrieved Employees.

1.11 “Class Notice” means the COURT APPROVED NOTICE OF CLASS ACTION SETTLEMENT AND HEARING DATE FOR FINAL COURT APPROVAL, to be mailed to Class Members in English [with a Spanish translation, if applicable] in the form, without material variation, attached as Exhibit A and incorporated by reference into this Agreement.

1.12 “Class Period” means the period from to .

1.13 “Class Representative” means the named Plaintiff in the operative complaint in the Action seeking Court approval to serve as a class representative.

1.14 “Class Representative Service Payment” means the payment to the Class Representative for initiating the Action and providing services in support of the Action.

1.15 “Court” means the Superior Court of California, County of Los Angeles.

1.16 “XYZ” means named Defendant .

1.17 “Defense Counsel” means .

1.18 “Effective Date” means the date on which the Judgment becomes final. The Judgment is final as of the latest of the following occurrences: (a) if no Participating Class Member objects to the Settlement, the day the Court enters Judgment; (b) if one or more Participating Class Members objects to the Settlement, the day after the deadline for filing a notice of appeal from the Judgment; or (c) if a timely appeal from the Judgment is filed, the day after the appellate court affirms the Judgment and issues a remittitur.

1.19 “Final Approval” means the Court’s order granting final approval of the Settlement.

2

SCLAC CIV 296 Rev. 04/26 For Optional Use

1.20 “Final Approval Hearing” means the Court’s hearing on the Motion for Final Approval of the Settlement.

1.21 “Gross Settlement Amount” means $ which is the total amount XYZ agrees to pay under the Settlement. The Gross Settlement Amount will be used to pay Individual Class Payments, Individual PAGA Payments, the LWDA PAGA Payment, Class Counsel Fees Payment, Class Counsel Litigation Expenses Payment, Class Representative Service Payment, and Administration Expenses Payment.

1.22 “Individual Class Payment” means the Participating Class Member’s pro rata share of the Net Settlement Amount calculated according to the number of Workweeks worked during the Class Period.

1.23 “Individual PAGA Payment” means the Aggrieved Employee’s pro rata share [25%/35%] of the PAGA Penalties calculated according to the number of PAGA Pay Periods worked during the PAGA Period.i

1.24 “Judgment” means the judgment entered by the Court based upon the Final Approval.

1.25 “LWDA” means the California Labor and Workforce Development Agency.

1.26 “LWDA PAGA Payment” means the [75%/65%] of the PAGA Penalties paid to the LWDA under Labor Code section 2699, subdivision (i).

1.27 “Net Settlement Amount” means the Gross Settlement Amount, less the following payments in the amounts approved by the Court: Individual PAGA Payments, LWDA PAGA Payment, Class Representative Service Payment, Class Counsel Fees Payment, Class Counsel Litigation Expenses Payment, and Administration Expenses Payment. The remainder is to be paid to Participating Class Members as Individual Class Payments.

1.28 “Non-Participating Class Member” means any Class Member who opts out of the Settlement by sending the Administrator a valid and timely Request for Exclusion.

1.29 “PAGA Pay Period” means any pay period during which an Aggrieved Employee worked for XYZ for at least one day during the PAGA Period.

1.30 “PAGA Period” means the period from to .

1.31 “PAGA” means the Private Attorneys General Act (Lab. Code, § 2698 et seq.).

1.32 “PAGA Notice” means Plaintiff’s letter to XYZ and the LWDA [and Plaintiff’s letter to XYZ and the LWDA] providing notice pursuant to Labor Code section 2699.3, subdivision (a).

3

SCLAC CIV 296 Rev. 04/26 For Optional Use

1.33 “PAGA Penalties” means the total amount of PAGA civil penalties to be paid from the Gross Settlement Amount, allocated [25%/35%] to the Aggrieved Employees ( ) and [75%/65%] to the LWDA ( ) in settlement of PAGA claims.

1.34 “Participating Class Member” means a Class Member who does not submit a valid and timely Request for Exclusion from the Settlement.

1.35 “Plaintiff” means , the named plaintiff in the Action.

1.36 “Preliminary Approval” means the Court’s order granting preliminary approval of the Settlement.

1.37 “Released Class Claims” means the claims being released as described in Paragraph 5.2 below.

1.38 “Released PAGA Claims” means the claims being released as described in Paragraph 5.3 below.

1.39 “Released Parties” means XYZ and each of its former and present [directors,] [officers,] [shareholders,] [owners,] [members,] [attorneys,] [insurers,] [predecessors,] [successors,] [assigns,] [subsidiaries,] [affiliates].

1.40 “Request for Exclusion” means a Class Member’s submission of a written request to be excluded from the Class Settlement signed by the Class Member.

1.41 “Response Deadline” means [e.g., 60] days after the Administrator mails the Class Notice and shall be the last date on which Class Members may: (a) fax, email or mail Requests for Exclusion, (b) fax, email or mail objections to the Settlement, or (c) fax, email or mail a challenge to the number of Workweeks allocated to the Class Member in the Class Notice. Class Members to whom Class Notices are resent after having been returned undeliverable to the Administrator shall have their deadline extended an additional [14] calendar days beyond the Response Deadline.

1.42 “Settlement” means the disposition of the Action effected by this Agreement and the Judgment.

1.43 “Workweek” means any week during which a Class Member worked for XYZ for at least one day, during the Class Period.ii

2. RECITALS.

   2.1 On , Plaintiff commenced this Action by filing a complaint alleging causes of action against XYZ for .] [On , Plaintiff filed a [e.g., First Amended Complaint] alleging causes of action against XYZ for . The [e.g., First Amended] Complaint is the operative complaint in the Action (the “Operative Complaint”).] XYZ denies the allegations in

SCLAC CIV 296 Rev. 04/26 4For Optional Use

the Operative Complaint, denies any failure to comply with the laws identified in in the Operative Complaint and denies any and all liability for the causes of action alleged.

2.2 Pursuant to Labor Code section 2699.3, subdivision (a), Plaintiff gave timely
written notice to XYZ and the LWDA by sending the PAGA Notice.

2.3 On , the
Parties participated in an all-day mediation presided over by which
led to this Agreement [or describe alternative means of negotiation].

2.4 Before [mediation] [negotiating the Settlement], Plaintiff obtained, through
[formal] [informal] discovery, .
Plaintiff’s investigation was sufficient to satisfy the criteria for court approval set forth in
Dunk v. Foot Locker Retail, Inc. (1996) 48 Cal.App.4th 1794, 1801 and Kullar v. Foot
Locker Retail, Inc. (2008) 168 Cal.App.4th 116, 129-130 (“Dunk/Kullar”).

2.5 The Court [has] [has not] granted class certification.

2.6 The Parties, Class Counsel and Defense Counsel represent [they are not aware of
any other pending matter or action asserting claims that will be extinguished or affected
by the Settlement] [they are aware of the following other pending matter[s] or action[s]
asserting claims that will be extinguished or affected by the Settlement:
, ].

3. MONETARY TERMS.

   3.1 Gross Settlement Amount. XYZ promises to pay $ _________ and no more as the Gross Settlement Amount [and to separately pay any and all employer payroll taxes owed on the Wage Portions (as defined below) of the Individual Class Payments.] XYZ has no obligation to pay the Gross Settlement Amount (or any payroll taxes) before the deadline stated in Paragraph 4.2.iii The Administrator will disburse the entire Gross Settlement Amount without asking or requiring Participating Class Members or Aggrieved Employees to submit any claim as a condition of payment. None of the Gross Settlement Amount will revert to XYZ.

   3.2 Payments from the Gross Settlement Amount. The Administrator will make and deduct the following payments from the Gross Settlement Amount, in the amounts specified by the Court in the Final Approval:

3.2.1 To Plaintiff: Class Representative Service Payment of not more than $ (in addition to any Individual Class Payment [and any Individual PAGA Payment] the Class Representative is entitled to receive as a Participating Class Member). XYZ will not oppose Plaintiff’s request for a Class Representative Service Payment that does not exceed this amount. As part of the Motion for Final Approval, Plaintiff will seek Court approval for any Class Representative Service Payment. If the Court approves a Class Representative Service Payment less than the amount 5 SCLAC CIV 296 Rev. 04/26 For Optional Use

requested, the Administrator will retain the remainder in the Net Settlement Amount. The Administrator will pay the Class Representative Service Payment using IRS Form 1099. Plaintiff assumes full responsibility and liability for employee taxes owed on the Class Representative Service Payment.

3.2.2 To Class Counsel: A Class Counsel Fees Payment of not more than %,
which is currently estimated to be $ , and a Class Counsel Litigation
Expenses Payment of not more than $ . XYZ will not oppose requests
for these payments provided they do not exceed these amounts. As part of the Motion
for Final Approval, Plaintiff and/or Class Counsel may seek Court approval of a
Class Counsel Fees Payment and Class Counsel Litigation Expenses Payment. In
support of the Class Counsel Litigation Expenses Payment, Class Counsel must
submit a cost ledger listing each expense incurred during the Action. If the Court
approves a Class Counsel Fees Payment or a Class Counsel Litigation Expenses
Payment less than the amount requested, the Administrator will allocate the
remainder to the Net Settlement Amount. Released Parties shall have no liability to
Class Counsel or any other Plaintiff’s Counsel arising from any claim to any portion
of any Class Counsel Fee Payment and/or Class Counsel Litigation Expenses
Payment. The Administrator will pay the Class Counsel Fees Payment and Class
Counsel Litigation Expenses Payment using one or more IRS 1099 Forms. Class
Counsel assumes full responsibility and liability for taxes owed on the Class Counsel
Fees Payment and the Class Counsel Litigation Expenses Payment and holds XYZ
harmless, and indemnifies XYZ, from any dispute or controversy regarding any
division or sharing of any of these payments.

3.2.3 To the Administrator: An Administration Expenses Payment not to exceed
$ except for a showing of good cause and as approved by the Court.
To the extent the administration expenses are less than or the Court approves
payment less than $ , the Administrator will retain the remainder in the
Net Settlement Amount.

3.2.4 To Each Participating Class Member: An Individual Class Payment,
which the Administrator shall calculate by (a) dividing the Net Settlement Amount
by the total number of Workweeks worked by all Participating Class Members
during the Class Period and (b) multiplying the result by each Participating Class
Member’s Workweeks.

3.2.4.1 Tax Allocation of Individual Class Payments. % of each Participating Class Member’s Individual Class Payment will be allocated to settlement of wage claims (the “Wage Portion”). The Wage Portions are subject to tax withholding and will be reported on an IRS W-2 Form. The % of each Participating Class Member’s Individual Class Payment will be allocated to settlement of claims for [e.g., interest and penalties] (the “Non-Wage Portion”).iv The Non-Wage Portions are not subject to wage withholdings and will be reported on IRS 1099 Forms. Participating Class Members assume full responsibility and liability for any employee taxes owed on their Individual Class Payment.

6

SCLAC CIV 296 Rev. 04/26 For Optional Use

3.2.4.2 Effect of Non-Participating Class Members on Calculation of Individual Class Payments. Non-Participating Class Members will not receive any Individual Class Payments. The Administrator will retain amounts equal to their Individual Class Payments in the Net Settlement Amount for distribution to Participating Class Members on a pro rata basis.

3.2.5 To the LWDA and Aggrieved Employees: PAGA Penalties in the amount
of $ to be paid from the Gross Settlement Amount, with [75%/65%]
($ ) allocated to the LWDA PAGA Payment and [25%/35%] ($ )
allocated to the Individual PAGA Payments.

3.2.5.1 The Administrator will calculate each Individual PAGA Payment
by (a) dividing the amount of the Aggrieved Employees’ [25%/35%] share of
PAGA Penalties ($ ) by the total number of PAGA Pay Periods worked
by all Aggrieved Employees during the PAGA Period and (b) multiplying the
result by each Aggrieved Employee’s PAGA Pay Periods. Aggrieved Employees
assume full responsibility and liability for any taxes owed on their Individual
PAGA Payment.

3.2.5.2 If the Court approves PAGA Penalties of less than the amount
requested, the Administrator will allocate the remainder to the Net Settlement
Amount. The Administrator will report the Individual PAGA Payments on IRS
1099 Forms.

4. SETTLEMENT FUNDING AND PAYMENTS.

   4.1 Class Size Estimates. Based on a review of its records to date, XYZ estimates there are Class Members who collectively worked a total of Workweeks, and Aggrieved Employees who worked a total of PAGA Pay Periods. v 4.2 Funding of Gross Settlement Amount. XYZ shall fully fund the Gross Settlement Amount, and also fund the amounts necessary to fully pay XYZ’s share of payroll taxes, by transmitting the funds to the Administrator no later than [14] days after the Effective Date.

   4.3 Payments from the Gross Settlement Amount. Within [14] days after XYZ funds the Gross Settlement Amount, the Administrator will mail checks for all Individual Class Payments, all Individual PAGA Payments, the LWDA PAGA Payment, the Administration Expenses Payment, the Class Counsel Fees Payment, the Class Counsel Litigation Expenses Payment, and the Class Representative Service Payment. Disbursement of the Class Counsel Fees Payment, the Class Counsel Litigation Expenses Payment and the Class Representative Service Payment shall not precede disbursement of Individual Class Payments and Individual PAGA Payments. 4.3.1 The Administrator will issue checks for the Individual Class Payments and Individual PAGA Payments and send them to the Class Members and Aggrieved 7

SCLAC CIV 296 Rev. 04/26 For Optional Use

Employees via First Class U.S. Mail, postage prepaid. The face of each check shall prominently state the date (not less than 180 days after the date of mailing) when the check will be voided. The Administrator will cancel all checks not cashed by the void date. The Administrator will send checks for Individual Settlement Payments to all Participating Class Members (including those for whom Class Notice was returned undelivered). The Administrator will send checks for Individual PAGA Payments to all Aggrieved Employees including Non-Participating Class Members who qualify as Aggrieved Employees (including those for whom Class Notice was returned undelivered). The Administrator may send Participating Class Members who are also Aggrieved Employees a single check combining the Individual Class Payment and the Individual PAGA Payment. Before mailing any checks, the Settlement Administrator must update the recipients’ mailing addresses using the National Change of Address Database.

4.3.2 The Administrator must conduct an Address Search for all Class
Members and Aggrieved Employees whose checks are returned undelivered without
a United States Postal Service (“USPS”) forwarding address. Within [7] days of
receiving a returned check the Administrator must re-mail the check to the USPS
forwarding address provided or to an address ascertained through the Address
Search. The Administrator need not take further steps to deliver checks to Class
Members or Aggrieved Employees whose re-mailed checks are returned as
undelivered. The Administrator shall promptly send a replacement check to any
Class Member or Aggrieved Employee whose original check was lost or misplaced,
as requested by the Class Member or Aggrieved Employee before the void date.

4.3.3 For any Class Member whose Individual Class Payment check is
uncashed and cancelled after the void date, the Administrator shall transmit the funds
represented by such a check [to a Court-approved nonprofit organization or
foundation consistent with Code of Civil Procedure section 384, subdivision (b) (“Cy
Pres Recipient”)] [to the California Controller’s Unclaimed Property Fund in the
name of the Class Member]. [ The Parties, Class Counsel and Defense Counsel
represent that they have no interest or relationship, financial or otherwise, with the
intended Cy Pres Recipient].

4.3.4 For any Aggrieved Employee whose Individual PAGA Payment check is
uncashed and cancelled after the void date, the Administrator shall transmit the funds
represented by such check to the California Controller’s Unclaimed Property Fund in
the name of the Aggrieved Employee thereby leaving no “unpaid residue” subject to
the requirements of Code of Civil Procedure section 384, subdivision (b).

4.3.5 The payment of Individual Class Payments and Individual PAGA
Payments shall not obligate XYZ to confer any additional benefits or make any
additional payments to Class Members or Aggrieved Employees (such as 401(k)
contributions or bonuses) beyond those specified in this Agreement.

5. RELEASES OF CLAIMS . Effective on the date when XYZ fully funds the entire Gross

Settlement Amount and funds all employer payroll taxes owed on the Wage Portion of the 8 SCLAC CIV 296 Rev. 04/26 For Optional Use

Individual Class Payments, Plaintiff, Class Members, Aggrieved Employees, and Class Counsel will release claims against all Released Parties as follows:

5.1 Plaintiff’s Release. Plaintiff and Plaintiff’s respective former and present
representatives, agents, attorneys, administrators, successors and assigns, release and
discharge Released Parties from all claims, transactions or occurrences [that occurred
during the Class Period], including, but not limited to:
(a) all claims that were, or reasonably could have been, alleged based on the facts
contained in the Operative Complaint and (b) all PAGA claims that were, or
reasonably could have been, alleged based on facts contained in the Operative
Complaint and Plaintiff’s PAGA Notice. (“Plaintiff’s Release.”) Plaintiff’s Release
does not extend to any claims or actions to enforce this Agreement, or to any claims
for vested benefits, unemployment benefits, disability benefits, social security
benefits, or workers’ compensation benefits that arose at any time, or based on
occurrences outside the Class Period. Plaintiff acknowledges that Plaintiff may
discover facts or law different from, or in addition to, the facts or law that Plaintiff
now knows or believes to be true but agrees, nonetheless, that Plaintiff’s Release shall
be and remain effective in all respects, notwithstanding such different or additional
facts or Plaintiff’s discovery of them.vi

5.1.1 Plaintiff’s Waiver of Rights Under Civil Code Section 1542. For purposes
of Plaintiff’s Release, Plaintiff expressly waives and relinquishes the provisions,
rights, and benefits, if any, of section 1542 of the Civil Code, which reads:

A general release does not extend to claims that the creditor or releasing party does
not know or suspect to exist in his or her favor at the time of executing the release,
and that if known by him or her would have materially affected his or her settlement
with the debtor or released party.

5.2 Release by Participating Class Members:
All Participating Class Members, on behalf of themselves and their respective former and
present representatives, agents, attorneys, administrators, successors and assigns, release
Released Parties from all claims that were alleged, or reasonably could have been
alleged, based on the facts and allegations in the Operative Complaint that are alleged to
have occurred during the Class Period [including, e.g., “(a) any and all claims involving
any alleged failure to pay minimum wage; etc.]. Except as set forth in Section 5.3 of this
Agreement, Participating Class Members do not release any other claims, including
claims for vested benefits, wrongful termination, violation of the Fair Employment and
Housing Act, unemployment insurance, disability, social security, or workers’
compensation or claims based on events occurring outside the Class Period.

5.3 Release by Aggrieved Employees:
All Aggrieved Employees are deemed to release, on behalf of themselves and their
respective former and present representatives, agents, attorneys, administrators,
successors and assigns, the Released Parties from all claims for PAGA Penalties that
were alleged, or reasonably could have been alleged, based on the facts and allegations
in the Operative Complaint that are alleged to have occurred during the PAGA Period
9

SCLAC CIV 296 Rev. 04/26 For Optional Use

and the PAGA Notice [including, e.g., “(a) any and all claims involving any alleged failure to pay minimum wage; etc.].

6. MOTION FOR PRELIMINARY APPROVAL. The Parties agree to jointly prepare and file a motion for preliminary approval (“Motion for Preliminary Approval”) that complies with the Court’s current checklist for Preliminary Approvals.

   6.1 XYZ’s Declaration in Support of Preliminary Approval. Within days of the full execution of this Agreement, XYZ will prepare and deliver to Class Counsel a signed declaration from XYZ and Defense Counsel disclosing all facts relevant to any actual or potential conflicts of interest with the Administrator and Cy Pres Recipient (if applicable). In their declarations, Defense Counsel and XYZ shall aver whether they are aware of any other pending matter or action asserting claims that will be extinguished or adversely affected by the Settlement.

   6.2 Plaintiff’s Responsibilities. Plaintiff will prepare and deliver to Defense Counsel all documents necessary for obtaining Preliminary Approval, including: (i) a draft of the notice and memorandum in support of the Motion for Preliminary Approval that includes an analysis of the Settlement under Dunk/Kullar and a request for approval of the PAGA Settlement under Labor Code section 2699, subdivision (f)(2); (ii) a draft proposed Order Granting Preliminary Approval and Approval of PAGA Settlement; (iii) a draft proposed Class Notice; (iv) a signed declaration from the Administrator attaching its “not to exceed” bid for administering the Settlement and attesting to its willingness to serve; competency; operative procedures for protecting the security of Class Data; amounts of insurance coverage for any data breach, defalcation of funds or other misfeasance; all facts relevant to any actual or potential conflicts of interest with Class Members [and/or the proposed Cy Pres Recipient]; and the nature and extent of any financial relationship with Plaintiff, Class Counsel or Defense Counsel; (v) a signed declaration from Plaintiff confirming willingness and competency to serve and disclosing all facts relevant to any actual or potential conflicts of interest with Class Members, [and/or] the Administrator [and/or the proposed Cy Pres Recipient]; (vi) a signed declaration from each Class Counsel firm attesting to its competency to represent the Class Members; and its timely transmission to the LWDA of all necessary PAGA documents (PAGA Notice (Lab. Code, § 2699.3, subd. (a)), Operative Complaint (Lab. Code, § 2699, subd. (l)(1)), and the Agreement (Lab. Code, § 2699, subd. (l)(2)); (vii) a redlined version of the Agreement showing all modifications made to the Superior Court of Los Angeles County’s Model Agreement; and (viii) all facts relevant to any actual or potential conflict of interest with Class Members, the Administrator and/or the Cy Pres Recipient. In their declarations, Plaintiff and Class Counsel shall aver whether they are aware of any other pending matter or action asserting claims that will be extinguished or adversely affected by the Settlement.

   6.3 Responsibilities of Counsel. Class Counsel and Defense Counsel are jointly responsible for expeditiously finalizing and filing the Motion for Preliminary Approval no later than [30] days after the full execution of this Agreement; obtaining a prompt hearing date for the Motion for Preliminary Approval; and appearing in Court to

10 SCLAC CIV 296 Rev. 04/26 For Optional Use

advocate in favor of the Motion for Preliminary Approval. Class Counsel is responsible for delivering the Court’s Preliminary Approval to the Administrator.

6.4 Duty to Cooperate. If the Parties disagree on any aspect of the proposed Motion
for Preliminary Approval and/or the supporting declarations and documents, Class
Counsel and Defense Counsel will expeditiously work together by meeting in person or
by telephone, and in good faith, to resolve the disagreement. If the Court does not grant
Preliminary Approval or conditions Preliminary Approval on any material change to
this Agreement, Class Counsel and Defense Counsel will expeditiously work together
by meeting in person or by telephone and in good faith to modify the Agreement and
otherwise satisfy the Court’s concerns.

7. SETTLEMENT ADMINISTRATION.

   7.1 Selection of Administrator. The Parties have jointly selected to serve as the Administrator and verified that, as a condition of appointment, agrees to be bound by this Agreement and to perform, as a fiduciary, all duties specified in this Agreement in exchange for the Administration Expenses Payment. The Parties and their Counsel represent that they have no interest or relationship, financial or otherwise, with the Administrator other than a professional relationship arising out of prior experiences administering settlements.

   7.2 Employer Identification Number. The Administrator shall have and use its own Employer Identification Number for purposes of calculating payroll tax withholdings and providing reports state and federal tax authorities.

   7.3 Qualified Settlement Fund. The Administrator shall establish a settlement fund that meets the requirements of a Qualified Settlement Fund under US Treasury Regulation section 468B-1.

   7.4 Notice to Class Members.

7.4.1 Not later than [e.g., 15] days after the Court grants Preliminary Approval, XYZ will deliver the Class Data to the Administrator, in the form of a Microsoft Excel spreadsheet. To protect Class Members’ privacy rights, the Administrator must maintain the Class Data in confidence, use the Class Data only for purposes of this Settlement and for no other purpose, and restrict access to the Class Data to Administrator employees who need access to effect and perform under this Agreement. XYZ has a continuing duty to immediately notify Class Counsel if it discovers that the Class Data omitted Class Member identifying information and to provide corrected or updated Class Data as soon as reasonably feasible. Without any extension of the deadline by which XYZ must send the Class Data to the Administrator, the Parties and their counsel will expeditiously use best efforts, in good faith, to reconstruct or otherwise resolve any issues related to missing or omitted Class Data. No later than three (3) business days after receipt of the Class Data, the Administrator shall notify Class Counsel that the list has been received and state the number of Class 11 SCLAC CIV 296 Rev. 04/26 For Optional Use

Members, Aggrieved Employees, Workweeks and PAGA Pay Periods in the Class Data.

7.4.2 Using best efforts to perform as soon as possible, and in no event later
than [14] days after receiving the Class Data, the Administrator will send to all
Class Members identified in the Class Data, via first-class USPS mail, the Class
Notice [with Spanish translation, if applicable] substantially in the form attached
to this Agreement as Exhibit . The first page of the Class Notice
shall prominently estimate the dollar amounts of any Individual Class Payment
and Individual PAGA Payment (if applicable) payable to the Class Member, and
the number of Workweeks and PAGA Pay Periods (if applicable) used to
calculate these amounts. Before mailing Class Notices, the Administrator shall
update Class Member addresses using the National Change of Address database.

7.4.3 Not later than [3] business days after the Administrator’s receipt of any
Class Notice returned by the USPS as undelivered, the Administrator shall re-mail
the Class Notice using any forwarding address provided by the USPS. If the
USPS does not provide a forwarding address, the Administrator shall conduct a
Class Member Address Search and re-mail the Class Notice to the most current
address obtained. The Administrator has no obligation to make further attempts
to locate or send Class Notice to Class Members whose Class Notice is returned
by the USPS a second time.

7.4.4 The deadline for Class Members’ written objections, challenges to
Workweeks, and Requests for Exclusion will be extended for Class Members
whose notices are re-mailed. Class Members to whom Class Notices are resent
after having been returned undeliverable to the Administrator shall have their
deadline extended an additional [14] calendar days beyond the Response
Deadline. The Administrator will inform the Class Member of the extended
deadline with the re-mailed Class Notice.

7.4.5 If the Administrator, XYZ or Class Counsel is contacted by or otherwise
discovers any persons who believe they should have been included in the Class
Data and should have received Class Notice, the Parties will expeditiously meet
and confer in person or by telephone, and in good faith, in an effort to agree on
whether to include them as Class Members. If the Parties agree, such persons will
be Class Members entitled to the same rights as other Class Members, and the
Administrator will send, via email or overnight delivery, a Class Notice requiring
them to exercise options under this Agreement not later than [14] days after
receipt of Class Notice, or the deadline dates in the Class Notice, which ever are
later.

7.5 Requests for Exclusion (Opt-Outs).

7.5.1 Class Members who wish to exclude themselves from (opt-out of) the
Class Settlement must send the Administrator, by fax, email, or mail, a signed
written Request for Exclusion not later than the Response Deadline. A Request
12

SCLAC CIV 296 Rev. 04/26 For Optional Use

for Exclusion is a letter from a Class Member or the Class Member’s representative that reasonably communicates the Class Member’s election to be excluded from the Settlement and includes the Class Member’s name, address and email address or telephone number. To be valid, a Request for Exclusion must be timely faxed, emailed, or postmarked by the Response Deadline.

7.5.2 The Administrator may not reject a Request for Exclusion as invalid
because it fails to contain all the information specified in the Class Notice. The
Administrator shall accept any Request for Exclusion as valid if the Administrator
can reasonably ascertain the identity of the person as a Class Member and the
Class Member’s desire to be excluded. The Administrator’s determination shall
be final and not appealable or otherwise susceptible to challenge. If the
Administrator has reason to question the authenticity of a Request for Exclusion,
the Administrator may demand additional proof of the Class Member’s identity.
The Administrator’s determination of authenticity shall be final and not
appealable or otherwise susceptible to challenge.

7.5.3 Every Class Member who does not submit a timely and valid Request for
Exclusion is deemed to be a Participating Class Member, entitled to all benefits
and bound by all terms and conditions of the Settlement, including the
Participating Class Members’ Release under Paragraph 5.2 of this Agreement,
regardless of whether the Participating Class Member actually receives the
Class Notice or objects to the Settlement.

7.5.4 Every Class Member who submits a valid and timely Request for
Exclusion is a Non-Participating Class Member and shall not receive an
Individual Class Payment or have the right to object to the class action
components of the Settlement. Because future PAGA claims are subject to claim
preclusion upon entry of the Judgment, Non-Participating Class Members who are
Aggrieved Employees are deemed to release the claims identified in Paragraph
5.3 of this Agreement and are eligible for an Individual PAGA Payment.

7.6 Challenges to Calculation of Workweeks. Each Class Member shall have until
the Response Deadline to challenge the number of Workweeks allocated to the Class
Member in the Class Notice. The Class Member may challenge the allocation by
communicating with the Administrator via fax, email or mail. The Administrator must
encourage the challenging Class Member to submit supporting documentation. The
Administrator has the authority to address and make final decisions consistent with the
terms of this Agreement on all Class Member challenges to the number of Workweeks.
In the absence of any contrary documentation, the Administrator is entitled to presume
that the Workweeks contained in the Class Notice are correct if they are consistent with
the Class Data. The Administrator’s determination of allocations of Workweeks is final
and not appealable or otherwise susceptible to challenge. The Administrator shall
promptly provide to Defense Counsel and Class Counsel copies of all challenges to
calculation of Workweeks and the Administrator’s determination of the challenges.

13

SCLAC CIV 296 Rev. 04/26 For Optional Use

7.7 Objections to Settlement.

7.7.1 Only Participating Class Members may object to the class action
components of the Settlement and this Agreement, including contesting the
fairness of the Settlement and the amounts requested for the Class Counsel Fees
Payment, Class Counsel Litigation Expenses Payment, Administration
Expenses Payment, and Class Representative Service Payment.

7.7.2 Participating Class Members may send written objections to the
Administrator, by fax, email or mail no later than the Response Deadline.
Participating Class Members may appear in Court (or hire an attorney to appear
in Court) to present oral objections at the Final Approval Hearing.

7.7.3 Non-Participating Class Members have no right to object to any of the
class action components of the Settlement.

7.8 Administrator Duties. The Administrator has a duty to perform all tasks to be
performed by the Administrator set forth in this Agreement or otherwise.

7.8.1 Website, Email Address and Toll-Free Number. The Administrator will
establish, maintain, and use a website to post information of interest to Class
Members including the date, time and location for the Final Approval Hearing
and copies of the Agreement, Motion for Preliminary Approval, the Preliminary
Approval, the Class Notice, the Motion for Final Approval, the Final Approval,
and the Judgment. The Administrator will also maintain and monitor an email
address and a toll-free telephone number to receive Class Member calls, faxes and
emails.

7.8.2 Requests for Exclusion (Opt-outs) and Exclusion List. The Administrator
will promptly review on a rolling basis Requests for Exclusion to ascertain their
validity. Not later than [5] days after the expiration of the deadline for submitting
Requests for Exclusion, the Administrator shall email a list to Class Counsel and
Defense Counsel containing (a) the names and other identifying information of
Class Members who have timely submitted valid Requests for Exclusion
(“Exclusion List”); (b) the names and other identifying information of Class
Members who have submitted invalid Requests for Exclusion; and (c) copies of
all Requests for Exclusion submitted (whether valid or invalid).

7.8.3 Weekly Reports. The Administrator must, on a weekly basis, provide
written reports to Class Counsel and Defense Counsel that, among other things,
tally the number of: Class Notices mailed or re-mailed, Class Notices returned
undelivered, Requests for Exclusion (whether valid or invalid) received,
objections received, challenges to Workweeks received and/or resolved, and
checks mailed for Individual Class Payments and Individual PAGA Payments
(“Weekly Report”). The Weekly Reports must include the Administrator’s

14

SCLAC CIV 296 Rev. 04/26 For Optional Use

assessment of the validity of Requests for Exclusion and attach copies of all Requests for Exclusion and objections received.

7.8.4 Administrator’s Declaration. Not later than [14] days before the date by
which Plaintiff is required to file the Motion for Final Approval of the Settlement,
the Administrator will provide to Class Counsel and Defense Counsel, a signed
declaration suitable for filing in Court attesting to its due diligence and
compliance with all of its obligations under this Agreement, including, but not
limited to, its mailing of Class Notice, the Class Notices returned as undelivered,
the re-mailing of Class Notices, attempts to locate Class Members, the total
number of Requests for Exclusion it received (both valid or invalid), and the
number of written objections. The declaration shall attach the Exclusion List.
The Administrator will supplement its declaration as needed or requested by the
Parties and/or the Court. Class Counsel is responsible for filing the
Administrator’s declaration(s) in Court.

7.8.5 Final Report by Settlement Administrator. Within [10] days after the
Administrator disburses all funds in the Gross Settlement Amount, the
Administrator will provide Class Counsel and Defense Counsel with a final report
detailing its disbursements by employee identification number only of all
payments made under this Agreement. At least [15] days before any deadline set
by the Court, the Administrator will prepare, and submit to Class Counsel and
Defense Counsel, a signed declaration suitable for filing in Court attesting to its
disbursement of all payments required under this Agreement. Class Counsel is
responsible for filing the Administrator’s declaration in Court.

8. XYZ’S RIGHT TO WITHDRAW. If the number of valid Requests for Exclusion identified in the Exclusion List exceeds % of the total of all Class Members, XYZ may, but is not obligated, elect to withdraw from the Settlement. The Parties agree that, if XYZ withdraws, the Settlement shall be void ab initio and have no force or effect whatsoever, and neither Party will have any further obligation to perform under this Agreement; provided, however, XYZ will remain responsible for paying all Settlement Administration Expenses incurred to that point. XYZ must notify Class Counsel and the Court of its election to withdraw not later than [seven] days after the Administrator sends the final Exclusion List to Defense Counsel; late elections will have no effect.

9. MOTION FOR FINAL APPROVAL. Not later than [16] court days before the calendared Final Approval Hearing, Plaintiff will file in Court, a motion for final approval that includes a request for approval of the PAGA settlement under Labor Code section 2699, subdivision (l), a proposed Final Approval Order and a proposed Judgment (collectively “Motion for Final Approval”). Plaintiff shall provide drafts of these documents to Defense Counsel not later than [seven] days before filing the Motion for Final Approval. Class Counsel and Defense Counsel will expeditiously meet and confer in person or by telephone, and in good faith, to resolve any disagreements concerning the Motion for Final Approval.

   15

SCLAC CIV 296 Rev. 04/26 For Optional Use

9.1 Response to Objections. Each Party retains the right to respond to any objection raised by a Participating Class Member, including the right to file responsive documents in Court no later that [five] court days before the Final Approval Hearing, or as otherwise ordered or accepted by the Court.

9.2 Duty to Cooperate. If the Court does not grant Final Approval or conditions Final
Approval on any material change to the Settlement (including, but not limited to, the
scope of release to be granted by Class Members), the Parties will expeditiously work
together in good faith to address the Court’s concerns by revising the Agreement as
necessary to obtain Final Approval. The Court’s decision to award less than the amounts
requested for the Class Representative Service Payment, Class Counsel Fees Payment,
Class Counsel Litigation Expenses Payment or Administration Expenses Payment shall
not constitute a material modification to the Agreement within the meaning of this
paragraph.

9.3 Continuing Jurisdiction of the Court. The Parties agree that, after entry of
Judgment, the Court will retain jurisdiction over the Parties, Action, and the Settlement
solely for purposes of (i) enforcing this Agreement or Judgment, (ii) addressing
settlement administration matters and (iii) addressing such post-Judgment matters as are
permitted by law.

9.4 Waiver of Right to Appeal. Provided the Judgment is consistent with the terms
and conditions of this Agreement, specifically including the Class Counsel Fees
Payment and Class Counsel Litigation Expenses Payment, the Parties, their respective
counsel and all Participating Class Members who did not object to the Settlement,
waive all rights to appeal from the Judgment, including all rights to post-judgment
and appellate proceedings, the right to file motions to vacate judgment, motions for
new trial, extraordinary writs and appeals. The waiver of appeal does not include any
waiver of the right to oppose such motions, writs or appeals. If an objector appeals
the Judgment, the Parties’ obligations to perform under this Agreement will be
suspended until such time as the appeal is finally resolved and the Judgment becomes
final, except as to matters that do not affect the Net Settlement Amount.

9.5 Appellate Court Orders to Vacate, Reverse or Materially Modify Judgment. If the
appellate court vacates, reverses or modifies the Judgment in a manner that requires a
material modification of this Agreement (including, but not limited to, the scope of
release to be granted by Class Members), this Agreement shall be null and void. The
Parties shall nevertheless expeditiously work together in good faith to address the
appellate court’s concerns and to obtain Final Approval and entry of Judgment, sharing,
on a 50-50 basis, any additional administration expenses reasonably incurred after
remittitur. An appellate decision to vacate, reverse or modify the Court’s award of the
Class Representative Service Payment or any payments to Class Counsel shall not
constitute a material modification of the Judgment within the meaning of this paragraph,
as long as the Gross Settlement Amount remains unchanged.

16

SCLAC CIV 296 Rev. 04/26 For Optional Use

10. AMENDED JUDGMENT. If any amended judgment is required under Code of Civil Procedure section 384, the Parties will work together in good faith to jointly submit a proposed amended judgment.

11. ADDITIONAL PROVISIONS.

11.1 No Admission of Liability. This Agreement represents a compromise and settlement of highly disputed claims. Nothing in this Agreement is intended or should be construed as an admission by XYZ that any of the allegations in the Operative Complaint have merit or that XYZ has any liability for any claims asserted; nor is it intended or should be construed as an admission by Plaintiff that XYZ’s defenses in the Action have merit. The Parties agree that class certification and representative treatment is for purposes of this Settlement only. If for any reason the Court does not grant Preliminary Approval, grant Final Approval, or enter Judgment, XYZ reserves the right to contest certification of any class for any reason, XYZ reserves all available defenses to the claims in the Action, and Plaintiff reserves the right to move for class certification on any grounds available and to contest XYZ’s defenses. The Settlement, this Agreement and Parties’ willingness to settle the Action will have no bearing on, and will not be admissible in connection with, any litigation (except for proceedings to enforce or effectuate the Settlement and this Agreement).

11.2 Confidentiality Before Preliminary Approval. Plaintiff, Class Counsel, XYZ and Defense Counsel separately agree that, until the Motion for Preliminary Approval is filed, they and each of them will not disclose, disseminate, publicize, or cause or permit another person to disclose, disseminate or publicize, any of the terms of the Agreement directly or indirectly, specifically or generally, to any person, corporation, association, government agency or other entity except: (1) to the Parties’ attorneys, accountants or spouses, all of whom will be instructed to keep this Agreement confidential; (2) to counsel in a related matter; (3) to the extent necessary to report income to appropriate taxing authorities; (4) in response to a court order or subpoena; or (5) in response to an inquiry or subpoena issued by a state or federal government agency. Each Party agrees to immediately notify each other Party of any judicial or agency order, inquiry, or subpoena seeking such information. Plaintiff, Class Counsel, XYZ and Defense Counsel separately agree not to, directly or indirectly, initiate any conversation or other communication, before the filing of the Motion for Preliminary Approval, with any third party regarding this Agreement or the matters giving rise to this Agreement except to respond only that “the matter was resolved,” or words to that effect. This paragraph does not restrict Class Counsel’s communications with Class Members in accordance with Class Counsel’s ethical obligations owed to Class Members.

11.3 No Solicitation. The Parties separately agree that they and their respective counsel and employees will not solicit any Class Member to opt out of or object to the Settlement or appeal from the Judgment. Nothing in this paragraph shall be construed to restrict Class Counsel’s ability to communicate with Class Members in accordance with Class Counsel’s ethical obligations owed to Class Members.

17

SCLAC CIV 296 Rev. 04/26 For Optional Use

11.4 Integrated Agreement. Upon execution by all Parties and their counsel, this Agreement together with its attached exhibits shall constitute the entire agreement between the Parties relating to the Settlement, superseding any and all oral representations, warranties, covenants or inducements made to or by any Party.

11.5 Attorney Authorization. Class Counsel and Defense Counsel separately warrant and represent that they are authorized by Plaintiff and XYZ, respectively, to take all appropriate action required or permitted to be taken by such Parties pursuant to this Agreement to effectuate its terms, and to execute any other documents reasonably required to effectuate the terms of this Agreement including any amendments to this Agreement.

11.6 Cooperation. The Parties and their counsel will cooperate with each other and use their best efforts in good faith to implement the Settlement by, among other things, modifying the Settlement Agreement and submitting supplemental evidence and supplementing points and authorities as requested by the Court. In the event the Parties are unable to agree upon the form or content of any document necessary to implement the Settlement, or on any modification of the Agreement that may become necessary to implement the Settlement, the Parties will seek the assistance of a mediator or the Court for resolution.

11.7 No Prior Assignments. The Parties separately represent and warrant that they have not directly or indirectly assigned, transferred, encumbered or purported to assign, transfer or encumber to any person or entity any portion of any liability, claim, demand, action, cause of action or right released and discharged by the Party in this Settlement.

11.8 No Tax Advice. Neither Plaintiff, Class Counsel, XYZ nor Defense Counsel are providing any advice regarding taxes or taxability, nor shall anything in this Settlement be relied upon as such within the meaning of United States Treasury Department Circular 230 (31 CFR Part 10, as amended) or otherwise.

11.9 Modification of Agreement. This Agreement, and all parts of it, may be amended, modified, changed or waived only by an express written instrument signed by all Parties or their representatives and approved by the Court.

11.10 Agreement Binding on Successors. This Agreement will be binding upon, and inure to the benefit of, the successors of each of the Parties.

11.11 Applicable Law. All terms and conditions of this Agreement and its exhibits will be governed by and interpreted according to the laws of the State of California, without regard to conflict of law principles.

11.12 Cooperation in Drafting. The Parties have cooperated in drafting and preparing this Agreement. This Agreement will not be construed against any Party on the basis that the Party was the drafter or participated in the drafting.

18 SCLAC CIV 296 Rev. 04/26 For Optional Use

11.13 Confidentiality. To the extent permitted by law, all agreements made and orders entered during the Action and in this Agreement relating to the confidentiality of information shall survive the execution of this Agreement.

11.14 Use and Return of Class Data. Information provided to Class Counsel pursuant to Evidence Code section 1152, and all copies and summaries of the Class Data provided to Class Counsel by XYZ in connection with the mediation, other settlement negotiations, or the Settlement, may be used only with respect to this Settlement and for no other purpose, and may not be used in any way that violates any existing contractual agreement, statute or the California Rules of Court. Not later than 90 days after the date when the Court discharges the Administrator’s obligation to provide a declaration confirming the final pay out of all Settlement funds, Plaintiff shall destroy all paper and electronic versions of Class Data received from XYZ unless, before the Court’s discharge of the Administrator’s obligation, XYZ makes a written request to Class Counsel for the return, rather than the destruction, of Class Data.

11.15 Headings. The descriptive heading of any section or paragraph of this Agreement is inserted for convenience of reference only and does not constitute a part of this Agreement.

11.16 Calendar Days. Unless otherwise noted, all references to “days” in this Agreement shall be to calendar days. In the event any date or deadline set forth in this Agreement falls on a weekend or federal legal holiday, such date or deadline shall be on the first business day thereafter.

11.17 Notice. All notices, demands or other communications between the Parties in connection with this Agreement will be in writing and deemed to have been duly given as of the third business day after mailing by United States mail, or the day sent by email or messenger, addressed as follows:

To Plaintiff:

To XYZ:

11.18 Execution in Counterparts. This Agreement may be executed in one or more counterparts by facsimile, electronically (i.e., DocuSign), or email which for purposes of this Agreement shall be accepted as an original. All executed counterparts and each of them will be deemed to be one and the same instrument if counsel for the Parties will exchange between themselves signed counterparts. Any executed counterpart will be admissible in evidence to prove the existence and contents of this Agreement. 19 SCLAC CIV 296 Rev. 04/26 For Optional Use

11.19 Stay of Litigation. The Parties agree that upon the execution of this Agreement the litigation shall be stayed, except to effectuate the terms of this Agreement. The Parties further agree that upon the signing of this Agreement that pursuant to Code of Civil Procedure section 583.330 to extend the date to bring a case to trial under Code of Civil Procedure section 583.310 for the entire period of this settlement process.

For Plaintiff For XYZ

(date) (date)

Counsel For Plaintiff Counsel For XYZ

(date) (date)

20

SCLAC CIV 296 Rev. 04/26 For Optional Use

COURT APPROVED NOTICE OF CLASS ACTION SETTLEMENT AND HEARING DATE FOR FINAL COURT APPROVAL [ ]

The Superior Court for the State of California authorized this Notice. Read it carefully! It’s not junk mail, spam, an advertisement or solicitation by a lawyer. You are not being sued.

You may be eligible to receive money from an employee class action lawsuit (“Action”)

against [abbreviate name; “XYZ” is used herein as a placeholder] for alleged wage and hour violations. The Action was filed by a [former] XYZ employee (“Plaintiff”) and seeks payment of (1) back wages [and other relief] for a class of [e.g., hourly] employees (“Class Members”) who worked for XYZ during the Class Period to ; and (2) penalties under the California Private Attorney General Act (“PAGA”) for all [e.g., hourly] employees who worked for XYZ during the PAGA Period ( to ) (“Aggrieved Employees”).

The proposed settlement has two main parts: (1) a class settlement requiring XYZ to fund

individual class payments, and (2) a PAGA settlement requiring XYZ to fund individual PAGA payments and pay penalties to the California Labor and Workforce Development Agency (“LWDA”).

Based on XYZ’s records, and the parties’ current assumptions, your individual class

payment is estimated to be $ (less withholding) and your individual PAGA payment is estimated to be $ . The actual amount you may receive likely will be different and will depend on a number of factors. (If no amount is stated for your individual PAGA payment, then according to XYZ’s records you are not eligible for an individual PAGA payment under the settlement because you didn’t work during the PAGA Period.)

The above estimates are based on XYZ’s records showing that you worked

workweeks during the Class Period and you worked workweeks during the PAGA Period. If you believe that you worked more workweeks during the Class Period, you can submit a challenge by the deadline date. See Section IV of this Notice.

The Court has already preliminarily approved the proposed settlement and approved this

notice. The Court has not yet decided whether to grant final approval. Your legal rights are affected whether you act or not act. Read this notice carefully. You will be deemed to have carefully read and understood it. At the final approval hearing, the Court will decide whether to finally approve the settlement and how much of the settlement will be paid to Plaintiff and Plaintiff’s attorneys (“Class Counsel”). The Court will also decide whether to enter a judgment that requires XYZ to make payments under the settlement and requires Class Members and Aggrieved Employees to give up their rights to assert certain claims against XYZ.

If you worked for XYZ during the Class Period and/or the PAGA Period, you have two

basic options under the settlement:

(1) Do Nothing. You don’t have to do anything to participate in the proposed settlement and be eligible for an individual class payment and/or an individual PAGA payment. As a participating class member, though, you will give up your right to assert Class 1 SCLAC CIV 296 Rev. 04/26 For Optional Use

Period wage claims against XYZ.

(2) Opt-Out of the Class Settlement. You can exclude yourself from the class settlement (opt-out) by submitting the written request for exclusion or otherwise notifying the Administrator in writing. If you opt-out of the settlement, you will not receive an individual class payment. You will, however, preserve your right to personally pursue Class Period wage claims against XYZ, and, if you are an Aggrieved Employee, remain eligible for an individual PAGA payment. You cannot opt-out of the PAGA portion of the proposed settlement.

XYZ will not retaliate against you for any actions you take with respect to the proposed settlement.

SUMMARY OF YOUR LEGAL RIGHTS AND OPTIONS IN THIS SETTLEMENT

You Don’t Have to Do If you do nothing, you will be a Participating Class Member, Anything to eligible for an individual class payment and an individual PAGA Participate in the payment (if any). In exchange, you will give up your right to assert Settlement the wage claims against XYZ that are covered by this settlement (“Released Claims”). You Can Opt-out of If you don’t want to fully participate in the proposed settlement, the Class Settlement you can opt-out of the class settlement by sending the but not the PAGA Administrator a written request for exclusion. Once excluded, you Settlement will be a Non-Participating Class Member and no longer eligible for an individual class payment. Non-Participating Class Members cannot object to any portion of the proposed settlement. See The Opt-out Deadline Section VI of this notice. is You cannot opt-out of the PAGA portion of the proposed settlement. XYZ must pay individual PAGA payments to all Aggrieved Employees, and the Aggrieved Employees must give up their rights to pursue Released Claims (defined below). Participating Class All Class Members who do not opt-out (“Participating Class Members Can Object Members”) can object to any aspect of the proposed settlement. to the Class Settlement The Court’s decision whether to finally approve the settlement will but not the PAGA include a determination of how much will be paid to Class Counsel Settlement and Plaintiff who pursued the Action on behalf of the Class. You are not personally responsible for any payments to Class Counsel Written Objections or Plaintiff, but every dollar paid to Class Counsel and Plaintiff Must be Submitted by reduces the overall amount paid to Participating Class Members. You can object to the amounts requested by Class Counsel or Plaintiff if you think they are unreasonable. See Section VII of this notice.

2

SCLAC CIV 296 Rev. 04/26 For Optional Use

You Can Participate in The Court’s final approval hearing is scheduled to take place on the . You don’t have to attend but you do have the Final Approval right to appear (or hire an attorney to appear on your behalf at your Hearing own cost), in person, by telephone or by using the Court’s virtual appearance platform. Participating Class Members can verbally object to the settlement at the final approval hearing. See Section VIII of this notice. You Can Challenge the The amount of your individual class payment and individual PAGA Calculation of Your payment (if any) depend on how many workweeks you worked at Workweeks/Pay least one day during the Class Period and how many pay periods Periods you worked at least one day during the PAGA Period, respectively. The number of Class Period workweeks and number of PAGA Written Challenges Period pay periods you worked according to XYZ’s records is Must be Submitted by stated on the first page of this notice. If you disagree with the number of Class Period workweeks, you must challenge it by . See Section IV of this notice.

I. WHAT IS THE ACTION ABOUT?

Plaintiff is a [former] XYZ employee. The Action accuses XYZ of violating California labor laws by failing to pay [e.g., overtime wages, minimum wages, wages due upon termination and reimbursable expenses] and failing to provide [e.g., meal periods, rest breaks and accurate itemized wage statements]. Based on the same claims, Plaintiff has also asserted a claim for civil penalties under the California Private Attorneys General Act (Lab. Code, § 2698, et seq.). Plaintiff is represented by attorneys in the Action: ____________________________________.

XYZ strongly denies violating any laws or failing to pay any wages and contends it complied with all applicable laws.

II. WHAT DOES IT MEAN THAT THE ACTION HAS SETTLED?

So far the Court has made no determination whether XYZ or Plaintiff is correct on the merits. In the meantime, Plaintiff and XYZ hired [an experienced, neutral mediator/a retired judge/ ] in an effort to resolve the Action by negotiating an agreement (settle the case) rather than continuing the expensive and time-consuming process of litigation. The negotiations were successful. By signing a settlement agreement and agreeing to ask the Court to enter a judgment ending the Action, Plaintiff and XYZ have negotiated a proposed settlement that is subject to the Court’s final approval. Both sides agree the proposed settlement is a compromise of disputed claims. By agreeing to settle, XYZ does not admit any violations or concede the merit of any claims. Plaintiff and Class Counsel strongly believe the settlement is a good deal for you because they believe that: (1) XYZ has agreed to pay a fair, reasonable and adequate amount considering the strength of the claims and the risks and uncertainties of continued litigation; and (2) settlement is in the best interests of the Class Members. The Court preliminarily approved the proposed settlement as fair, reasonable and adequate, authorized this Notice, and scheduled a hearing to determine final approval.

3

SCLAC CIV 296 Rev. 04/26 For Optional Use

III. WHAT ARE THE IMPORTANT TERMS OF THE PROPOSED SETTLEMENT?

1. XYZ Will Pay $ as the Gross Settlement Amount (“Gross Settlement”).
XYZ has agreed to deposit the Gross Settlement into an account controlled by the
Administrator of the settlement. The Administrator will use the Gross Settlement to pay
the individual class payments, individual PAGA payments, a class representative service
payment, Class Counsel’s attorneys’ fees and expenses, the Administrator’s expenses,
and penalties to be paid to the LWDA. Assuming the Court grants final approval, XYZ
will fund the Gross Settlement not more than [14] days after the judgment entered by the
Court becomes final. The judgment will be final on the date the Court enters judgment, or
a later date if Participating Class Members object to the proposed settlement or the
judgment is appealed.

2. Court Approved Deductions from Gross Settlement. At the final approval hearing,
Class Counsel will ask the Court to approve the following deductions from the Gross
Settlement, the amounts of which will be decided by the Court:

A. Up to $ [ % of the Gross Settlement] to Class Counsel for
attorneys’ fees and up to $ for their litigation expenses. To date,
Class Counsel have worked and incurred expenses on the Action without
payment.

B. Up to $ to Plaintiff as a class representative award for filing the
Action, working with Class Counsel and representing the Class. A class
representative award will be the only monies Plaintiff will receive other than
Plaintiff’s individual class payment and any individual PAGA payment.

C. Up to $ to the Administrator for services administering the settlement.

D. Up to $ for PAGA penalties, allocated [75%/65%] to the LWDA
and [25%/35%] to individual PAGA payments to Aggrieved Employees based
on their pay periods during the PAGA Period.

Participating Class Members have the right to object to any of these deductions except
the PAGA penalties. The Court will consider all objections.

3. Net Settlement Distributed to Class Members. After making the above deductions in
amounts approved by the Court, the Administrator will distribute the rest of the Gross
Settlement (the “Net Settlement”) by making individual class payments to Participating
Class Members based on their Class Period workweeks.

4. Taxes Owed on Payments to Class Members. Plaintiff and XYZ are asking the Court to approve an allocation of % of each individual class payment to taxable wages (“Wage Portion”) and % to [e.g., interest, etc.] (“Non-Wage Portion”). The Wage Portion is subject to withholdings and will be reported on IRS W-2 Forms. [Option 1: (XYZ will separately pay employer payroll taxes it owes on the Wage Portion.)] The individual PAGA payments are counted as penalties rather than wages for tax purposes. The Administrator will report the individual PAGA payments and the Non-Wage Portions of the individual class payments on IRS 1099 Forms. 4

SCLAC CIV 296 Rev. 04/26 For Optional Use

Although Plaintiff and XYZ have agreed to these allocations, neither side is giving you any advice on whether your payments are taxable or how much you might owe in taxes. You are responsible for paying all taxes (including penalties and interest on back taxes) on any payments received from the proposed settlement. You should consult a tax advisor if you have any questions about the tax consequences of the proposed settlement.

5. Need to Promptly Cash Payment Checks. The front of every check issued for individual
class payments and individual PAGA payments will show the date when the check
expires (the void date). If you don’t cash it by the void date, your check will be
automatically cancelled, and the monies [will be deposited with the California
Controller’s Unclaimed Property Fund in your name] [will irrevocably be lost to you
because they will be paid to a non-profit organization or foundation].

[If the monies represented by your check is sent to the Controller’s Unclaimed Property
Fund, you should consult the rules of the fund for instructions on how to retrieve your
money.]

6. Requests for Exclusion from the Class Settlement (Opt-Outs). You will be treated as a
Participating Class Member, participating fully in the class settlement, unless you notify
the Administrator in writing, not later than , that you wish to opt-out.
The easiest way to notify the Administrator is to send a written and signed request for
exclusion by the response deadline. The request for exclusion should be
a letter from the Class Member or Class Member’s representative setting forth the Class
Member’s name, present address, telephone number, and a simple statement electing to
be excluded from the settlement. Class Members who opt out will not receive individual
class payments, but will preserve their rights to personally pursue wage and hour claims
against XYZ.

You cannot opt-out of the PAGA portion of the settlement. Class Members who opt out of
the class settlement remain eligible for individual PAGA payments and are required to give
up their right to assert PAGA claims against XYZ based on the PAGA Period facts alleged
in the Action.

7. The Proposed Settlement Will be Void if the Court Denies Final Approval. It is possible
the Court will not grant final approval of the settlement or not enter a judgment. It is
also possible the Court will enter a judgment that is reversed on appeal. Plaintiff and
XYZ have agreed that, in either case, the settlement will be void, XYZ will not pay any
money, and Class Members will not release any claims against XYZ.

8. Administrator. The Court has appointed a neutral company,
(the “Administrator”) to send this notice, calculate
and make payments, and process Class Members’ requests for exclusion. The
Administrator will also decide Class Member challenges over Workweeks, mail and re-
mail settlement checks and tax forms, and perform other tasks necessary to administer the
settlement. The Administrator’s contact information is contained in Section IX of this
notice.

5

SCLAC CIV 296 Rev. 04/26 For Optional Use

9. Participating Class Members’ Release. After the Judgment is final and XYZ has fully funded the Gross Settlement [(and separately paid all employer payroll taxes)], Participating Class Members will be legally barred from asserting any of the claims released under the settlement. This means that unless you opted out by validly excluding yourself from the class settlement, you cannot sue, continue to sue or be part of any other lawsuit against XYZ or related entities for wages based on the Class Period facts and PAGA penalties based on PAGA Period facts, as alleged in the Action and resolved by this settlement.

   The Participating Class Members will be bound by the following release:

   All Participating Class Members, on behalf of themselves and their respective former and present representatives, agents, attorneys, administrators, successors and assigns, release Released Parties from (i) all claims that were alleged, or reasonably could have been alleged, based on the facts and allegations in the Operative Complaint that are alleged to have occurred during the Class Period [including, e.g., “(a) any and all claims involving any alleged failure to pay minimum wage; etc.]. Except as set forth in Section 5.3 of the Settlement Agreement, Participating Class Members do not release any other claims, including claims for vested benefits, wrongful termination, violation of the Fair Employment and Housing Act, unemployment insurance, disability, social security, workers’ compensation, or claims based on events occurring outside the Class Period.vii

   10. Aggrieved Employees’ PAGA Release. After the Court’s judgment is final, and XYZ has paid the Gross Settlement (and separately paid the employer-side payroll taxes), all Aggrieved Employees will be barred from asserting PAGA claims against XYZ, whether or not they exclude themselves from the Settlement. This means that all Aggrieved Employees, including those who are Participating Class Members and those who opt-out of the class settlement, cannot sue, continue to sue or participate in any other PAGA claim against XYZ or its related entities based on the PAGA Period facts alleged in the Action and resolved by this settlement.

   The Aggrieved Employees’ Release is as follows:

   All Aggrieved Employees are deemed to release, on behalf of themselves and their respective former and present representatives, agents, attorneys, administrators, successors, and assigns, the Released Parties, from all claims for PAGA penalties that were alleged, or reasonably could have been alleged, based on the facts and allegations in the Operative Complaint that are alleged to have occurred during the

   PAGA Period and the PAGA Notice [including, e.g., (a) any and all claims involving any alleged failure to pay minimum wage; etc.]. viii

IV. HOW WILL THE ADMINISTRATOR CALCULATE MY PAYMENT?

1. Individual Class Payments. The Administrator will calculate individual class payments by (a) dividing the Net Settlement Amount by the total number of Workweeks worked by all Participating Class Members, and (b) multiplying the result by the number of Workweeks worked by each individual Participating Class Member. 6

SCLAC CIV 296 Rev. 04/26 For Optional Use

2. Individual PAGA Payments. The Administrator will calculate individual PAGA payments by (a) dividing $ by the total number of PAGA Period pay periods worked by all Aggrieved Employees and (b) multiplying the result by the number of PAGA Period pay periods worked by each individual Aggrieved Employee.

   3. Workweek Challenges. The number of Workweeks you worked during the Class Period, as recorded in XYZ’s records, is stated in the first page of this notice. You have until _ to challenge the number of Workweeks credited to you.

   You can submit your challenge by signing and sending a letter to the Administrator via mail, email or fax. Section IX of this notice has the Administrator’s contact information.

   You need to support your challenge by sending copies of pay stubs or other records. The Administrator will accept XYZ’s calculation of Workweeks based on XYZ’s records as accurate unless you send copies of records containing contrary information. You should send copies rather than originals because the documents will not be returned to you. The Administrator will resolve Workweek challenges based on your submission and on input from Class Counsel (who will advocate on behalf of Participating Class Members) and XYZ’s Counsel. The Administrator’s decision is final. You can’t appeal or otherwise challenge its final decision.

V. HOW WILL I GET PAID?

1. Participating Class Members. The Administrator will send, by U.S. mail, a single check to every Participating Class Member (i.e., every Class Member who doesn’t opt-out) including those who also qualify as Aggrieved Employees. The single check will combine the individual class payment and the individual PAGA payment (if any).

2. Non-Participating Class Members. The Administrator will send, by U.S. mail, a single individual PAGA payment check to every Aggrieved Employee who opts out of the class settlement.

Your check will be sent to the same address as this notice. If you change your address, be sure to notify the Administrator as soon as possible. Section IX of this notice has the Administrator’s contact information.

VI. HOW DO I OPT-OUT OF THE CLASS SETTLEMENT?

To opt out of the class action settlement, submit a written and signed letter with your name, present address, telephone number and a simple statement that you do not want to participate in the settlement. The Administrator will exclude you based on any writing communicating your request be excluded. Be sure to personally sign your request, identify the Action as , and include your identifying information (full name, address, telephone number, approximate dates of employment and social security number for verification purposes). You must make the request yourself. If someone else makes the request for you, it will not be valid. You must send your request to be excluded to the Administrator by , or it will be invalid. Section IX of the notice has the Administrator’s contact information. 7 SCLAC CIV 296 Rev. 04/26 For Optional Use

VII. HOW DO I OBJECT TO THE SETTLEMENT?

Only Participating Class Members have the right to object to the settlement. Before deciding
whether to object, you may wish to see what Plaintiff and XYZ are asking the Court to
approve. At least days before the final approval hearing, Class
Counsel and/or Plaintiff will file in Court a Motion for Final Approval that includes, among
other things, the reasons why the proposed settlement is fair and states (i) the amount Class
Counsel is requesting for attorneys’ fees and litigation expenses; and (ii) the amount Plaintiff
is requesting as a class representative service award. Upon reasonable request, Class
Counsel (whose contact information is in Section IX of this Notice) will send you copies of
these documents at no cost to you. You can also view them on the Administrator’s website
or the Court’s website .

A Participating Class Member who disagrees with any aspect of the settlement or the Motion for Final Approval may wish to object, for example, that the proposed settlement is unfair, or that the amounts requested by Class Counsel or Plaintiff are too high or too low. The deadline for sending written objections to the Administrator is . Be sure to tell the Administrator what you object to, why you object and any facts that support your objection. Make sure you identify the Action and include your name, current address, telephone number and approximate dates of employment for [XYZ] and sign the objection. Section IX of this notice has the Administrator’s contact information.

A Participating Class Member can object (or personally retain a lawyer to object at your own cost) by attending the final approval hearing. You (or your attorney) should be ready to tell the Court what you object to, why you object, and any facts that support your objection. See Section VIII of this notice (immediately below) for specifics regarding the final approval hearing.

VIII. CAN I ATTEND THE FINAL APPROVAL HEARING?

You can, but don’t have to, attend the final approval hearing on at in Department [____] of the Superior Court of Los Angeles County, located at 312 North Spring Street, Los Angeles, CA 90012. At the hearing, the judge will decide whether to grant final approval of the settlement and how much of the Gross Settlement will be paid to Class Counsel, Plaintiff and the Administrator. The Court will invite comment from objectors, Class Counsel and defense counsel before making a decision. You can attend (or hire a lawyer to attend) either personally or virtually via LACourtConnect (https://www.lacourt.org/lacc/). Check the Court’s website for the most current information.

It’s possible the Court will reschedule the final approval hearing. You should check the Administrator’s website beforehand or contact Class Counsel to verify the date and time of the final approval hearing.

IX. HOW CAN I GET MORE INFORMATION?

The settlement agreement sets forth everything XYZ and Plaintiff have promised to do under the proposed settlement. The easiest way to read the settlement agreement, the judgment or any other settlement documents is to go to website at . You can also telephone or send an email to Class Counsel or the Administrator using the contact 8 SCLAC CIV 296 Rev. 04/26 For Optional Use

information listed below, or consult the Superior Court website by going to (http://www.lacourt.org/casesummary/ui/index.aspx) [confirm] and entering the Case Number for the Action, Case No. . You can also make an appointment to personally review court documents in the Clerk’s Office at the Stanley Mosk Courthouse by calling (213) 830-0800.

DO NOT TELEPHONE THE COURT TO OBTAIN INFORMATION ABOUT THE SETTLEMENT

Class Counsel: Name of Attorney: Email Address: Name of Firm: Mailing Address: Telephone:

Settlement Administrator: Name of Company: Email Address: Mailing Address: Telephone: Fax Number:

X. WHAT IF I LOSE MY SETTLEMENT CHECK?

If you lose or misplace your settlement check before cashing it, the Administrator will replace it as long as you request a replacement before the void date on the face of the original check. If your check is already void, [you should consult the Unclaimed Property Fund for instructions on how to retrieve the funds] [you will have no way to recover the money].

XI. WHAT IF I CHANGE MY ADDRESS?

To receive your check, you should immediately notify the Administrator if you move or otherwise change your mailing address.

i For PAGA settlements involving PAGA notice letters sent to the LWDA after June 19, 2024, ensure that Plaintiff complies with the new PAGA requirements established by S.B. 92 and A.B. 2288. The PAGA penalty allocation in the Settlement Agreement should be revised to reflect the updated structure detailed in Lab. Code, § 2699(m) – 65% of the amount to the LWDA, 35% to Aggrieved Employees. ii The Parties may need to tailor this language to pay periods or shifts depending on the facts of the case. iii The Parties are free to negotiate a payment plan structure if appropriate. In the motion for preliminary approval, counsel should submit evidence (e.g., declaration from a representative of Defendant) explaining the financial necessity for a payment plan. iv Note that this is not the only possible appropriate breakdown depending on the claims at issue in the case (e.g., a settlement that is solely a Labor Code section 226, subdivision (a) claim). v Insert any negotiated terms addressing the possibility that XYZ’s estimates of Class size, Workweeks, or PAGA Pay Periods turn out to be understated or concerning an “escalator” clause memorializing XYZ’s promise to increase the Gross Settlement Amount in an agreed-upon proportion to the percentage by which the calculated class size, Workweeks, or PAGA Pay Periods exceed XYZ’s estimates. Counsel must finalize the end dates of the Class and PAGA Periods before filing the Motion for Preliminary Approval and submit evidence showing if the escalator clause has been triggered and the consequences. vi The Parties can negotiate and propose a broader individual release for Plaintiff’s claims. vii Releases in the Notice should be verbatim to the releases in the Settlement Agreement. viii Releases in the Notice should be verbatim to the releases in the Settlement Agreement. 9 SCLAC CIV 296 Rev. 04/26 For Optional Use