Haynes Properties, LLC, et al. v. Burley Tobacco Growers Cooperative Association

Case No. 20-CI-332

COMMONWEALTH OF KENTUCKY, Fayette Circuit Court, Fourth Division

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Settlement Amount

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W-9 Information

Because your Settlement Amount is over $600.00, the U.S. Internal Revenue Service (“IRS”) requires that the Settlement Administrator collect Form W-9 information to issue a Settlement Payment. The information you provide on the Form W-9 will be encrypted and stored with utmost confidentiality and information security, and will only be provided to the IRS for reporting purposes.

MAIL:
Settlement Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103

PHONE: (833) 277-8323

EMAIL: Info@BTGCASettlement.com

Request for Taxpayer Identification Number and Certification

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner.

(Applies to accounts outside the U.S.)

Part ITaxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter.

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or

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Part IICertification

Under penalities of perjury, I certify that:

  1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
  2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
  3. I am a U.S. citizen or other U.S. person (defined below); and
  4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

General Instructions

Section references are to the Internal Revenue Code unless otherwise noted.

Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9.

Purpose of Form

An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following.

  • Form 1099-INT (interest earned or paid)
  • Form 1099-DIV (dividends, including those from stocks or mutual funds)
  • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
  • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)
  • Form 1099-S (proceeds from real estate transactions)
  • Form 1099-K (merchant card and third party network transactions)
  • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)
  • Form 1099-C (canceled debt)
  • Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later.

By signing the filled-out form, you:

  1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),
  2. Certify that you are not subject to backup withholding, or
  3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and
  4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information.

Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

  • An individual who is a U.S. citizen or U.S. resident alien;
  • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;
  • An estate (other than a foreign estate); or
  • A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States.

  • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;
  • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and
  • In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items.

  1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.
  2. The treaty article addressing the income.
  3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions.
  4. The type and amount of income that qualifies for the exemption from tax.
  5. Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

  1. You do not furnish your TIN to the requester,
  2. You do not certify your TIN when required (see the instructions for Part II for details),
  3. The IRS tells the requester that you furnished an incorrect TIN,
  4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or
  5. You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships, earlier.

What is FATCA Reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9.

  1. Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

    Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.
  2. Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.
  3. Partnership, LLC that is not a single-member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.
  4. Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.
  5. Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.

IF the entity/person on line 1 is a(n) ... THEN check the box for ...
  • Corporation
Corporation
  • Individual
  • Sole proprietorship, or
  • Single-member limited liability company (LLC) owned by an individual and disregarded for U.S. federal tax purposes.
Individual/sole proprietor or single-member LLC
  • LLC treated as a partnership for U.S. federal tax purposes,
  • LLC that has filed Form 8832 or 2553 to be taxed as a corporation, or
  • LLC that is disregarded as an entity separate from its owner but the owner is another LLC that is not disregarded for U.S. federal tax purposes.
Limited liability company and enter the appropriate tax classification. (P= Partnership; C= C corporation; or S= S corporation)
  • Partnership
Partnership
  • Trust/estate
Trust/estate

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.

Exempt payee code.

  • Generally, individuals (including sole proprietors) are not exempt from backup withholding.
  • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.
  • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.
  • Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

  1. An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)
  2. The United States or any of its agencies or instrumentalities
  3. A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities
  4. A foreign government or any of its political subdivisions, agencies, or instrumentalities
  5. A corporation
  6. A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession
  7. A futures commission merchant registered with the Commodity Futures Trading Commission
  8. A real estate investment trust
  9. An entity registered at all times during the tax year under the Investment Company Act of 1940
  10. A common trust fund operated by a bank under section 584(a)
  11. A financial institution
  12. A middleman known in the investment community as a nominee or custodian
  13. A trust exempt from tax under section 664 or described in section 4947

The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13.

IF the payment is for ... THEN the payment is exempt for ...
Interest and dividend payments All exempt payees except for 7
Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012.
Barter exchange transactions and patronage dividends Exempt payees 1 through 4
Payments over $600 required to be reported and direct sales over $5,0001 Generally, exempt payees 1 through 52
Payments made in settlement of payment card Exempt payees 1 through 4

1See Form 1099-MISC, Miscellaneous Income, and its instructions.

2However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency.

Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) written or printed on the line for a FATCA exemption code.

  1. An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37)
  2. The United States or any of its agencies or instrumentalities
  3. A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities
  4. A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i)
  5. A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i)
  6. A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state
  7. A real estate investment trust
  8. A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940
  9. A common trust fund as defined in section 584(a)
  10. A bank as defined in section 581
  11. A broker
  12. A trust exempt from tax under section 664 or described in section 4947(a)(1)
  13. A tax exempt trust under a section 403(b) plan or section 457(g) plan

Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed.

Line 5

Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, write NEW at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records.

Line 6

Enter your city, state, and ZIP code.

Part I. Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. If you are a resident alien and you do not have and are not eligible to get an SSN, your TIN is your IRS individual taxpayer identification number (ITIN). Enter it in the social security number box. If you do not have an ITIN, see How to get a TIN below.

If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN.

If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). Do not enter the disregarded entity’s EIN. If the LLC is classified as a corporation or partnership, enter the entity’s EIN.

Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations.

How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 1-800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/Businesses and clicking on Employer Identification Number (EIN) under Starting a Business. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or SS-4 mailed to you within 10 business days.

If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and write “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, generally you will have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester.

Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon.

Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8.

Part II. Certification

To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise.

For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier.

Signature requirements. Complete the certification as indicated in items 1 through 5 below.

  1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification.
  2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form.
  3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification.
  4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations).
  5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification.

What Name and Number To Give the Register

For this type of account: Give name and SSN of:
  1. Individual
  2. Two or more individuals (joint account) other than an account maintained by an FFI
  3. Two or more U.S. persons (joint account maintained by an FFI)
  4. Custodial account of a minor (Uniform Gift to Minors Act)
  5. a. The usual revocable savings trust (grantor is also trustee)
    b. So-called trust account that is not a legal or valid trust under state law
  6. Sole proprietorship or disregarded entity owned by an individual
  7. Grantor trust filing under Optional Form 1099 Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))
  1. The individual
  2. The actual owner of the account or, if combined funds, the first individual on the account1
  3. Each holder of the account
  4. The minor2
  5. a.The grantor-trustee1
    b.The actual owner1
  6. The owner3
  7. The grantor*
For this type of account: Give name and EIN of:
  1. Disregarded entity not owned by an individual
  2. A valid trust, estate, or pension trust
  3. Corporation or LLC electing corporate status on Form 8832 or Form 2553
  4. Association, club, religious, charitable, educational, or other taxexempt organization
  5. Partnership or multi-member LLC
  6. A broker or registered nominee
  7. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments
  8. Grantor trust filing under the Form 1041 Filing Method or the Optional Form 1099 Filing Method 2 (see Regulations section 1.671-4(b)(2)(i)(B))
  1. The owner
  2. Legal entity4
  3. The corporation
  4. The organization
  5. The partnership
  6. The broker or nominee
  7. The public entity
  8. The trust

1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished.

2 Circle the minor’s name and furnish the minor’s SSN.

3 You must show your individual name and you may also enter your business or DBA name on the “Business name/disregarded entity” name line. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN.

4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) Also see Special rules for partnerships, earlier.

*Note: The grantor also must provide a Form W-9 to trustee of trust.

Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed.

Secure Your Tax Records From Identity Theft

Identity theft occurs when someone uses your personal information such as your name, SSN, or other identifying information, without your permission, to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund.

To reduce your risk:

  • Protect your SSN,
  • Ensure your employer is protecting your SSN, and
  • Be careful when choosing a tax preparer.

If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter.

If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity or credit report, contact the IRS Identity Theft Hotline at 1-800-908-4490 or submit Form 14039.

For more information, see Pub. 5027, Identity Theft Information for Taxpayers.

Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft.

The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts.

If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 1-800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027.

Visit www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their laws. The information also may be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payers must generally withhold a percentage of taxable interest, dividend, and certain other payments to a payee who does not give a TIN to the payer. Certain penalties may also apply for providing false or fraudulent information.

Terms of Settlement and Release

This Confidential Settlement Agreement and Release of All Claims (“Confidential Agreement”) is entered into by and between (“Claimant”), on the one hand, and BTGCASettlement, Inc. (“BTGCASettlement”) and its subsidiary Caviar, LLC (“Caviar”)1, on the other (each individually a “Party” and collectively the “Parties”). In consideration of the mutual covenants and promises in this Confidential Agreement, the Parties agree as follows.

  1. Claims
    1. Claimant has filed, is prepared to file, and/or could file arbitration demands with the American Arbitration Association (“AAA”), the International Institute for Conflict Prevention & Resolution (“CPR”) or JAMS, or litigation in any court, asserting claims that BTGCASettlement and/or Caviar misclassified Claimant as an independent contractor and thereby violated certain federal, state, and local laws, and any other claims arising from their relationship with BTGCASettlement and/or Caviar as applicable. All such claims are referred to herein as the “Claims.”
    2. Claimant represents that except for the Claims referenced above, Claimant has no other charges, lawsuits, or claims of any kind against BTGCASettlement, Caviar, or any other Released Party (as that term is defined in Section 5 below) presently pending before any state, federal or other court, any state or federal agency, any other governmental entity, or any arbitration provider. Claimant is not aware of any Claims Claimant has or could have against BTGCASettlement, Caviar or any other Released Party except for those Released Claims as described in Section 5. If, arguendo, any such charges, lawsuits, claims, or arbitration demands are pending, Claimant agrees to immediately dismiss or withdraw the same with prejudice.
  2. No Admission of Wrongdoing or Liability. By entering into this Confidential Agreement, neither Claimant nor BTGCASettlement admits any liability as to the other, and none of the Parties admits the allegations or contentions of any other Party. Each Party is entering into this Confidential Agreement for the sole purpose of resolving the Claims and avoiding the expense incident to protracted litigation and/or arbitration.
  3. Consideration. In exchange for the promises contained herein, including Claimant’s release of all Claims against BTGCASettlement and Caviar, and provided that all conditions precedent to payment described herein have been satisfied, BTGCASettlement shall pay to Claimant a total of .

    This amount has been calculated in part based on the total amount of on-delivery miles driven by Claimant as of [insert date], while making deliveries using the BTGCASettlement and/or Caviar platforms.

    Consistent with Claimant’s classification as an independent contractor, no deductions or withholding for taxes or otherwise shall be taken from these amounts, for which BTGCASettlement and/or Caviar will issue an IRS Form 1099 (if required). Claimant shall, at the same time Claimant executes this Confidential Agreement and delivers it to BTGCASettlement, provide to the Settlement Administrator information necessary for an IRS Form 1099 to be issued (if required). Claimant agrees that, absent this Confidential Agreement, Claimant would not be entitled to this payment. Claimant agrees to timely pay in full any federal, state, or local tax owed on such payments.

    Claimant and BTGCASettlement agree that the consideration set forth in this Section is sufficient consideration for the Release given by Claimant in Section 5 and Claimant’s other promises in this Confidential Agreement.

  4. Taxes. Claimant understands and expressly agrees that in the event any income or other taxes, including any interest and/or penalties, are determined to be owed by Claimant as a result of the payment described in Section 3 above or as a result of violation by Claimant of any reporting obligations arising from or attributable to said amounts, Claimant is solely responsible for the payment of such amounts. Claimant agrees to indemnify BTGCASettlement for any amounts Claimant should have paid if BTGCASettlement is required to pay such amounts on Claimant’s behalf.

    Neither BTGCASettlement nor its counsel has made any representations regarding the taxability of the payments to be made pursuant to this Confidential Agreement. Claimant represents that Claimant has had an opportunity to receive independent legal advice regarding the taxability of any sums payable to Claimant and has not relied upon any representation of BTGCASettlement or its counsel on that subject.

  5. Release by Claimant. Claimant, on behalf of Claimant and Claimant’s executors, legatees, devisees, administrators, successors and assigns, does hereby and forever release and discharge BTGCASettlement and its predecessor, successor, parent, subsidiary (including but not limited to Caviar, LLC and its predecessor Caviar, Inc.), sister and affiliated corporations, divisions and other related entities, as well as the successors, predecessors, owners, investors, officers, directors, partners, heirs, assigns, agents, employees, attorneys and representatives of each of them (“Released Parties”), from any and all causes of action, judgments, liens, indebtedness, costs, damages, obligations, attorneys’ fees, losses, claims, liabilities and demands of whatever kind and character arising out of or in any way related to Claimant’s relationship with BTGCASettlement and/or Caviar, use of the BTGCASettlement and/or Caviar platforms, classification as an independent contractor, or the allegations in the Claims.

    Claimant specifically releases any and all past, present and future claims, demands, actions, suits, causes of action, obligations, damages, rights or liabilities, of any nature, kind or description whatsoever, regardless of the legal or equitable theory, that Claimant has or may have against BTGCASettlement, Caviar, or any of the Released Parties which arise or arose at any point in time beginning from the date of Claimant’s first interaction with BTGCASettlement or Caviar and continuing through, up to, and including the Effective Date, including without limitation all assigned and derivative claims, whether known or unknown, asserted or unasserted, foreseen or unforeseen, contingent or absolute, suspected or unsuspected, disclosed or undisclosed, apparent or unapparent, pursuant to any theory of recovery, including whether based in tort, contract, statute, common law, public policy, or other legal theory and including unknown claims covered by California Civil Code Section 1542. Claimant’s released claims include, but are not limited to, any claims against BTGCASettlement, Caviar, or any Released Party arising directly or indirectly, out of, relating to, or in any way connected to any alleged act, omission, misconduct, misrepresentation, transmission, breach, breach of contract, or occurrence. The Released Claims further include, but are not limited to, claims under the Fair Labor Standards Act, 29 U.S.C. §§ 201, et seq.; claims relating to any screening conducted by BTGCASettlement or Caviar pertaining to background screening, including under the Fair Credit Reporting Act, 15 U.S.C. §§ 1681, et seq., and any state analogues; claims arising out of related to any Independent Contractor Agreement and any other express or implied agreements between Claimant and BTGCASettlement or Caviar, including any demand for arbitration and any right to invoke any arbitration agreement contained therein, and any other express or implied agreements between Claimants and BTGCASettlement; claims under any law pertaining to employment, misclassification (including any allegations regarding BTGCASettlement’s or Caviar’s tipping policy related in any way to misclassification), hours of work, payment of wages, unpaid compensation, wage and hour violations, unpaid costs, reimbursement of expenses, or any other perquisites of employment; claims under any other federal, state, county, city, or local law, ordinance, rule, or regulation regarding employment, wages or compensation (and all of their implementing regulations and interpretive guidelines), including but not limited to (i) the California Labor Code (including §§ 132a, 200 et seq., 300 et seq., 400 et seq., 500 et seq., 1174, 1174.5, 1182.12, 1194, 1194.2, 1194.3, 1197, 1197.1, 1198, 1280, 1281.96, 1281.97, 1281.98, 1281.99, 2753, 2802, 2804, 2810.5, 2698 et seq., 4553 et seq.), (ii) California Code of Civil Procedure section 1021.5; (iii) California Business and Professions Code sections 17200 et seq., (iv) California Code of Regulations, title 8, sections 11010, 11040 and 11090, (v) any applicable California Industrial Welfare Commission Wage Orders, and (vi) any claims for employee benefits under any state or federal law, including without limitation, any claims under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq., all as amended; and any claims of discrimination on any basis under any state, federal, or local law, including without limitation, (i) Title VII of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000 et seq., (ii) the Civil Rights Act of 1866, 42 U.S.C. § 1981, (iii) the Civil Rights Act of 1991, (iv) the Americans with Disabilities Act, 42 U.S.C. §§ 12101 et seq., (v) the Family and Medical Leave Act of 1993, all as amended, and (vi) the Los Angeles Office of Wage Standards Ordinance, the San Francisco Admin. Code Minimum Wage Ordinance, and any other similar state or local ordinances. The Released Claims further include, but are not limited to, claims for any form of damages or relief, including liquidated damages, and claims for restitution, statutory or other penalties (including under California’s Private Attorneys General Act (“PAGA”)), punitive damages, equitable relief, litigation costs, interest, attorneys’ fees, or any other form of relief. All claims covered by this Release are collectively referred to in this Confidential Agreement as the “Released Claims.” This Release (a) shall not affect any claims that Claimant may have which arise solely after the Effective Date of this Confidential Agreement and (b) shall not serve as a release of any claims that cannot be released as a matter of law.2

    Each Released Party is an intended beneficiary of the releases and agreements set forth in this Confidential Agreement, and on that basis is entitled to enforce this Confidential Agreement to the extent he, she or it is benefited by any release, covenant or provision of this Confidential Agreement.

    Claimant expressly acknowledges and agrees that, by virtue of this Confidential Agreement, Claimant is not and cannot be an aggrieved employee under PAGA (and therefore has no standing under PAGA) to pursue any claim or action alleging California Labor Code violations against any Released Party on behalf of Claimant, any other individual, or the State of California.

  6. No Future Claims. Claimant shall not file or cause to be filed and shall not prosecute in any manner any claims, charges, or actions against BTGCASettlement, Caviar, or any other Released Party at any time with respect to any Released Claim. If any agency, tribunal, arbitration provider, or court assumes jurisdiction over any such claim, charge or action against any of the Released Parties, Claimant shall request and take all available actions to cause such agency, tribunal, arbitration provider, or court to dismiss the matter with prejudice. Claimant also agrees that Claimant shall not accept any remedy relating in any way to any Released Claim from any such agency, tribunal, arbitration provider, or court.

  7. Express Waiver. Except as set forth above, Claimant expressly waives and relinquishes all rights and benefits afforded by Section 1542 of the Civil Code of the State of California, and any other relevant jurisdiction’s equivalent statute, and does so understanding and acknowledging the significance and consequence of such specific waiver of Section 1542. Section 1542 of the Civil Code of the State of California states as follows:

    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.

    Thus, notwithstanding the provisions of Section 1542, and for the purpose of implementing a full and complete release and discharge of all claims and disputes, except as otherwise provided herein, Claimant expressly acknowledges that this Confidential Agreement is intended to release, without limitation, all claims whether known or unknown, and all disputes which Claimant does not know or suspect to exist at the time of signature of this Confidential Agreement, and that this Confidential Agreement contemplates the extinguishment of any and all such claims and disputes.

  8. No Disparaging Comments. Claimant agrees that Claimant will not disparage or encourage or induce others to disparage BTGCASettlement, Caviar, or any of the Released Parties. For purposes of this Confidential Agreement, “disparage” includes, without limitation, making oral or written comments or statements to any person or entity, including, without limitation, to the press and/or media, employees, partners or principals of BTGCASettlement or Caviar, or any entity with which BTGCASettlement or Caviar has a business relationship, which would adversely affect in any manner (a) the conduct of the business of BTGCASettlement, or (b) the reputation of any Released Party.
  9. New Independent Contractor Agreement. Claimant agrees that BTGCASettlement has the right to require Claimant to sign a new Independent Contractor Agreement in order to continue to use the BTGCASettlement platform.
  10. Confidentiality. The Parties agree that confidentiality is one of the most important terms of this Confidential Agreement and that the fact and terms of this Confidential Agreement are a private matter. Claimant agrees that Claimant will not directly or indirectly divulge or disclose the fact or terms of this Confidential Agreement, the amount of the settlement, or any of the settlement negotiations or communications leading to this Confidential Agreement (collectively, “Confidential Information”) except as follows:

    1. Claimant may disclose Confidential Information in response to a valid subpoena or other legal process compelling disclosure of Confidential Information, on the condition that, upon receipt of a subpoena or other legal process compelling any disclosure of Confidential Information, Claimant (i) shall immediately notify and provide a copy of all relevant documentation by email to BTGCASettlement at ___@BTGCASettlement.com, and (ii) shall take all available actions to postpone disclosing Confidential Information to allow BTGCASettlement a full opportunity to intervene and otherwise act to protect its rights in the Confidential Information.
    2. Claimant may disclose the terms of this Confidential Agreement to Claimant’s spouse or domestic partner, on the condition that Claimant’s spouse or domestic partner is informed of Claimant’s obligation to keep this Confidential Agreement confidential, and promises to comply with the terms of this Confidential Agreement, and Claimant instructs his/her spouse or domestic partner not to disclose the fact or terms of this Confidential Agreement.
    3. Claimant may disclose the terms of this Confidential Agreement to Claimant’s tax advisors and attorneys, but only to the extent that it is required for the rendering of professional services, and on the condition that the person is informed of Claimant’s obligation to keep this Confidential Agreement confidential prior to the disclosure of the information, and promises to comply with the terms of the Confidential Agreement, and Claimant instructs them not to disclose the fact or terms of this Confidential Agreement.
    4. If Claimant is ever asked about the resolution of this matter, Claimant (and Claimant’s counsel and/or tax advisor) may say only “The matter has been resolved,” or “The matter is over with,” without elaboration, and without stating or implying payment of settlement funds.

    Claimant represents that Claimant has not discussed this Confidential Agreement, its contents, the amount of the settlement or the existence or contents of the settlement negotiations leading to this Confidential Agreement with any person except with their spouse or domestic partner, the attorneys and employees of Zimmerman Reed, their counsel, or as necessary to obtain tax advice from a tax advisor. Claimant represents and agree Claimant has instructed and will continue to instruct Claimant’s spouse or domestic partner, employees, and tax advisors to hold all Confidential Information confidential and to comply with the provisions of this Section 10.

    Claimant agrees that Claimant will not issue or make any press release or press statement, respond to any press inquiry, or initiate or respond to media coverage or other publicity regarding BTGCASettlement, Caviar, the Released Parties, or this Confidential Agreement, nor post any notice on any website, listserv or social media, nor otherwise publicize any aspect or term of this settlement. Claimant agrees Claimant shall not disclose or communicate, directly or indirectly, with any other attorneys, any past, present or future Dasher any information about this settlement or any terms of this Confidential Agreement.

    Claimant agrees that any material breach or threatened breach of this Section shall entitle BTGCASettlement, Caviar, and all Released Parties to damages and immediate injunctive relief to prevent further breach and injury. The Parties acknowledge and agree that the time and expense involved in proving actual damages resulting from violation of this Confidentiality provision render any breach appropriate for liquidated damages. Accordingly, in lieu of requiring actual proof of damages or losses, the Parties agree that, for each breach by Claimant, BTGCASettlement will receive from Claimant a payment of liquidated damages in an amount equal to 10% of the total settlement payment to which Claimant is entitled under this Confidential Agreement, not to exceed $5,000. Claimant agrees that BTGCASettlement, Caviar, and Released Parties shall also be entitled to recover reasonable attorneys’ fees for any action taken in response to Claimant’s knowing breach of this Section.

    The Parties intend that this confidentiality provision be construed as broadly as possible in order to provide the maximum confidentiality.

  11. Arbitration. Any dispute arising out of this Confidential Agreement shall be resolved exclusively by final and binding arbitration, before a single arbitrator, in San Francisco, California pursuant to the then-applicable CPR rules, policies, and/or procedures for employment-related disputes provided, however, that any claims, which by law may not be submitted to arbitration are not covered by this arbitration provision. The arbitration provided for herein shall be in lieu of any civil action, and any decision resulting from such arbitration shall be final and binding, and enforceable by any competent court of law. Judgment upon any such arbitration award may be entered by any state or federal court of competent jurisdiction. In the event any Party to this Confidential Agreement initiates any arbitration action or proceeding in connection with enforcement of this Confidential Agreement, the prevailing party in such action or proceeding shall be entitled to recover its reasonable costs, arbitration administration and arbitrator’s fees, and attorneys’ fees from the non-prevailing party. This Confidential Agreement shall be admissible in any proceeding to enforce its terms. Notwithstanding the mandatory arbitration procedures set forth in this Confidential Agreement, Claimant or BTGCASettlement may seek emergency, temporary or preliminary injunctive relief from a court of competent jurisdiction to seek enforcement of Section 9 or 10 and/or in aid of arbitration or pending final adjudication of a claim in arbitration where the arbitration award may be rendered ineffectual without such relief. To the extent permitted by law, the Parties further agree that instead of AAA, JAMS or any other arbitration forum, any dispute subject to the arbitration provision in any Independent Contractor Agreement between Claimant and BTGCASettlement or Caviar shall be subject to the then-applicable CPR rules. Should Claimant enter into a new arbitration agreement pursuant to a new Independent Contractor Agreement with BTGCASettlement or Caviar, such arbitration agreement shall govern and supersede this Paragraph 11 to the extent that there are any inconsistencies between the two agreements.
  12. Governing Law. This Confidential Agreement shall be governed by the substantive law of the State of California.
  13. Severability. If any provision of this Confidential Agreement is determined to be invalid or unenforceable, all of the other provisions shall remain valid and enforceable notwithstanding, unless the provision found to be unenforceable is of such material effect that this Confidential Agreement cannot be performed in accordance with the intent of the Parties in the absence thereof.
  14. No Assignment. Claimant represents and warrants that no other person or entity has or has had any interest in any of the claims or matters being resolved by this Confidential Agreement, and that Claimant has the sole right and exclusive authority to execute this Confidential Agreement and receive the sums specified in it; and that Claimant has not sold, assigned, transferred, conveyed or otherwise disposed of any interest in any claims, demands, obligations, or causes of action released in this Confidential Agreement. Claimant represents and warrants that Claimant has the authority to enter into this Confidential Agreement and that no approval or consent of any third party is either necessary or a condition precedent to the formation or the enforcement of this Confidential Agreement.
  15. Each Side To Bear Own Legal Fees and Costs. The payment described in Section 3 includes any and all costs and attorneys’ fees to which Claimant may be entitled. Accordingly, each Party hereto shall bear all of its or Claimant’s own attorneys’ fees and costs/expenses including any fees and costs/expenses owing to or incurred by its or his own counsel in connection with this matter, this Confidential Agreement, and all related matters, except as provided in Section 10.
  16. Cooperation. Each Party agrees to cooperate fully and execute and deliver any and all supplementary documents and to take all additional actions, which reasonably may be necessary or appropriate to give full force and effect to the terms and intent of this Confidential Agreement without the receipt of further consideration.
  17. Entire Agreement. No promise, inducement or agreement other than that expressed in this Confidential Agreement has been made by either Party. This Confidential Agreement constitutes a single integrated contract expressing the entire agreement of the Parties hereto and supersedes all previous understandings, whether written or oral. There are no other agreements, written or oral, express or implied, between the Parties concerning the subject matter of this Confidential Agreement.
  18. Modification. This Confidential Agreement can be amended, modified or terminated only by a writing executed by Claimant, Claimant’s counsel, and the Chief Legal Officer of BTGCASettlement.
  19. No Implied Waiver. The waiver of any breach or failure of any Party to enforce any provision of this Confidential Agreement shall not operate as or be construed to be a waiver by that Party of any other breach or provision of this Confidential Agreement.
  20. No Prejudice to the Drafter. Each Party has had a full and complete opportunity to review this Confidential Agreement, and make suggestions or changes, as has counsel for each Party. Accordingly, this Confidential Agreement is deemed to have been drafted jointly by the Parties and the Parties agree that the principle of construing ambiguities against the drafter shall not apply to this Confidential Agreement.
  21. Execution in Counterparts and by Facsimile. This Confidential Agreement may be executed in one or more counterparts, all of which shall constitute one and the same document. Counterparts may be exchanged by email directed to counsel for the Parties. Each counterpart, whether bearing an original signature or an electronically scanned or DocuSign signature, shall be deemed an original as against any party who signed it.
  22. Effective Date. This Confidential Agreement shall be effective when it is fully executed by all Parties (“Effective Date”) or December 31, 2020, whichever is earlier. BTGCASettlement will have until January 15, 2021 to countersign this Confidential Agreement.
  23. Claimant’s Representation. Claimant states that Claimant is in good health and fully competent to manage his business affairs, that Claimant has carefully read this Confidential Agreement, that Claimant fully understands its final and binding effect, that the only promises made to Claimant to sign this Confidential Agreement are those stated and contained in this Confidential Agreement, and that Claimant is signing this Confidential Agreement knowingly and voluntarily.

1For the avoidance of doubt, “BTGCASettlement” will be interpreted to include Caviar except where otherwise specified.

2Although this Template Release covers all federal, state, and local claims, for the avoidance of doubt, BTGCASettlement reserves the right to enumerate additional specific federal, state, or local claims depending on the specific Claimant.


Agreed and Accepted

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