Assurance of Discontinuance Between the Office of the Attorney General of the State of New York, the Office of Labor Policy and Standards in the New York City Department of Consumer Affairs, and Starbucks Corporation

Assurance No. 19-155

ADJC No. 15860-2019-ADJC

If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

OR

If you did not receive a personalized Notice in the mail or via email, but believe you are a potential class member, click here to download a Claim Form and submit it via email at info@StarbucksAODClaim.com.

The deadline for submitting this proof of claim form is November 24, 2020

Provide Your Contact Information

If your name differs from what is printed above, please provide updates here:

* Required Fields

To be eligible to receive compensation, you must complete and submit the below. Both sections A and B must be completed.

If you have questions about completing this Claim Form, please email info@StarbucksAODClaim.com or call (833) 649-0906.

Please attach any relevant documents in the documentation section below.

A. Please provide documentary evidence and/or a narrative description of the time(s) you believe you (1) were required to find a replacement in order to use sick leave, or (2) were disciplined for not finding a replacement in connection with the use of sick leave.
B. Please provide the following information regarding your claim(s). Sections 1 and 2, and either 3 or 4 must be completed.

1. Store Location(s)

2. Approximate Date(s) and Purpose(s) of Usage

3. Manager(s) or Supervisor(s) Contacted Regarding the Usage

4. Potential Substitute Employee(s) Contacted Regarding the Usage

Please explain why your claim submission was delayed.

Supporting Documentation

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

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    You must sign and date your Claim Form below in order to be eligible to receive compensation.

    I hereby declare under penalty of perjury that the information and facts I have stated in this Claim Form, and any additional pages included, are true and accurate to the best of my personal knowledge.

    Your Claim Form has been submitted successfully.

    HOWEVER, it appears one or more of the documents you uploaded were not successfully received. Please see below for which file(s) had errors and log back in to your existing Claim online to re-upload your document(s). Alternatively, you can send your documents with your Submitted Claim ID to the Settlement Administrator by email to: info@StarbucksAODClaim.com.

    Please print this page for your records.

    Your Claim Details

    Submitted Claim ID:
    Confirmation Code:
    You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
    CLAIM INFORMATION
    First Name
    Last Name
    Street Address
    Street Address 2
    City
    State
    Zip Code
    Email Address
    Phone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at info@StarbucksAODClaim.com

    Click here to edit your Claim.