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MacLellan Claim

Release of Claims:

In consideration for my receipt of a share of settlement funds, I forever release and discharge J.G. MacLellan Concrete Co., Inc., John G. MacLellan III, and all other Releasees set forth in the Settlement Agreement and Release of Claims of any actions, claims, demands, suits, or causes of action, known or unknown, including for damages, rights, liabilities, penalties, attorneys’ fees, costs, expenses, multiple damages, and interest, that were asserted or could have been asserted in the Lawsuit or that are based upon the facts alleged in the Lawsuit, up to June 5, 2023.

By signing below, I declare and verify that I have read this Claim Form, and that I agree to participate in the Settlement on the terms described herein, including the Release of Claims set forth above.

First Name:

Last Name:

Street Address:

Unit/Apt #:

City:

State:

Zip Code:

Mobile Phone:

E-mail:

Optime Administration, LLC – Substitute IRS Form W-9 & W4

Please print your Social Security Number (SSN):

Check One:

Single

Married

Married, but withhold at higher Single rate.

Total number of allowances you are claiming:

Additional amount, if any, you want withheld from settlement payment:

Under penalty of perjury, I certify that:

The social security number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and
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
I am a U.S. person (including a U.S. resident alien)

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Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

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January 8, 2026 1:54 pm EDT

MacLellan Claim Uploaded by Optime Administration, LLC - MACLELLANSETTLEMENT@OPTIMEADMIN.COM IP 71.234.148.75