CLAIM FORM

FOR MASSAGE ENVY FRANCHISING, LLC CLASS ACTION SETTLEMENT

US DISTRICT COURT, NORTHERN DISTRICT OF CALIFORNIA

CASE NO. 3-12-cv-06327-NC

Please type or print any changes below:

BARCODE

CLASS MEMBER NAME

ADDR1

ADDR2

CITY STATE ZIP

DATED: September 24, 2014

TO: CLAIMANT NAME

GENERAL INSTRUCTIONS

Please read this carefully. You may be entitled to a Settlement payment in the above-named case.

This Claim Form relates to the Settlement of a class action lawsuit entitled Balderas v. Massage

Envy Franchising, LLC, et al., Case No. 3-12-cv-06327-NC, currently pending in the United Stated

District Court for the Northern District of California (the “Action”). You are receiving this notice

because you have been identified as a Massage Therapist at one or more California Massage Envy

clinics or spas (“California Franchises”) who may be entitled to receive a Settlement benefit if the

Settlement is approved by the Court.

This Claim Form must be postmarked no later than December 8, 2014, if you wish to make a claim.

For further information, see the Notice of Proposed Class Action Settlement sent with this Claim Form,

and/or the Settlement Agreement which is available at www.MTbusinessExpenseSettlement.com.

Please print clearly using dark ink. Failure to complete this form may result in your claim being

delayed or denied. You will need to sign this Claim Form at the end of Section 2 to certify under

penalty of perjury that the information you provide is true to the best of your knowledge. Please be aware

that Claim Forms may be verified to confirm the accuracy of any statements made. Claim Forms that

are not signed will be considered invalid, and will prevent you from receiving payment.

Mailing Instructions. Mail this completed Claim Form to the Settlement Administrator, MT Business

Expense Settlement Administrator, postmarked on or before December 8, 2014, at the following

address:

MT Business Expense Settlement Administrator

P.O. Box 3614

Minneapolis, MN 55403-0614

1-888-755-9508

Questions. Please note that there is additional information available at the Settlement Website which is

available at www.MTbusinessExpenseSettlement.com. You may also contact MT Business Expense

Settlement Administrator at the above-referenced address or telephone number, or Class Counsel at:

Monique Olivier, Esq.

Duckworth Peters Lebowitz Olivier LLP

100 Bush Street, Suite 1800

San Francisco, CA 94104

Tel: (415) 433-0333 x 6

Monique@dplolaw.com

SECTION 1. CONTACT INFORMATION Name: _______________________________________________________________________________ My current address is: __________________________________________________________________ _____________________________________________________________________________________ My daytime telephone number is: ( ____ ____ ____ ) ____ ____ ____ - ____ ____ ____ ____ My evening telephone number is: ( ____ ____ ____ ) ____ ____ ____ - ____ ____ ____ ____ The last four digits of my Social Security Number are: ____ ____ ____ ____ My email address is: __________________________________________________________________ SECTION 2. CERTIFICATION I was employed as a massage therapist by a California Massage Envy franchise at some point between

October 15, 2008 and July 21, 2014. During that time, I paid for and was not reimbursed for, or had

deducted from my wages, the following costs (check all that apply):

Professional Liability Insurance

For one year

For two or more years

Application for California Massage Therapy Council Certification or local licensing or

certification

LiveScan fee in conjunction with California Massage Therapy Council Certification or local

licensing or certification

I have read this Claim Form. I declare under penalty of perjury under California law that all of the

information I provided in this Claim Form is true and correct to the best of my knowledge. The

release and waivers of claims, found in the accompanying Notice of Class Action Settlement, are

given knowingly and voluntarily.

______________________________________________ ___________________________

Signature Date (dd/mm/yyyy)

BE SURE TO SIGN THIS FORM ABOVE AND SUBMIT IT TO THE SETTLEMENT

ADMINISTRATOR POSTMARKED NO LATER THAN DECEMBER 8, 2014

MT Business Expense Settlement Administrator

P.O. Box 3614

Minneapolis, MN 55403-0614