Claim Form
Contact Information
Provide your name and contact information below. It is up to you to keep your address updated with the Settlement Administrator to receive payments and/or tax forms related to the payment.
Employment Information
In the table below, please provide information as best you can about the liquor or retail store(s) that you worked for in 2020, 2021, 2022, and/or 2023. This includes the Store Name, Store Number (if known), Store Location, and the Estimated Dates of Employment when you made deliveries. You must provide at least one (1) row of data to complete this form.
| Store Name | Store Number | Store Location | Estimated Dates of Employment |
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Payment Election
Please select one of the following payment options, which will be used should you be eligible to receive a settlement payment.
IMPORTANT NOTES:
For PayPal, Venmo, and Zelle payments, if there are any discrepancies, if the account is no longer active, or if the Settlement Administrator deems that payment cannot or should not be made based on the provided information, the Claims Administrator will either contact you for clarification or be authorized to default to a Check payment.
If domestic or international payment limits apply to your payment, you may receive more than one transmission or you may default to a Check payment.
Venmo and Zelle payments cannot be made to accounts outside of the United States.
Payments by Check will be made out to the Business or Individual name on this Claim Form and mailed to the address on this Claim Form.
Note: In accordance with the New York State Personal Privacy Protection Law, any personal information that you may provide, such as your name, address and/or banking information, will only be used to process your payment. Simpluris will retain your personal information in a secure database for only so long as is needed to process your payment and report such payment to the OAG. If you have concerns about data safety, privacy, or submitting your personal information, please contact labor.bureau@ag.ny.gov for further information.
Attestation & Signature
By signing below, I affirm under the penalties of perjury under the laws of New York, which may include a fine or imprisonment, that the foregoing is true, and I understand that this document may be filed in an action or proceeding in a court of law before my claim is considered complete and valid.