FLSA Consent to Sue Form

FLSA Consent to Sue Form

I, Employee Name: , residing at Address: , Telephone: , Email: (hereinafter "Claimant"), do hereby knowingly and voluntarily CONSENT to become a party plaintiff in a lawsuit under the Fair Labor Standards Act, 29 U.S.C. §216(b), against Employer: .

RECITALS

WHEREAS, Claimant alleges that during the period of employment with Employer identified above, Claimant performed work for which Claimant was not paid all wages and/or overtime compensation due under the Fair Labor Standards Act;

WHEREAS, Claimant understands that under 29 U.S.C. §216(b) any individual asserting FLSA claims may become a party plaintiff by filing a written consent to join the collective action; and

WHEREAS, Claimant wishes to opt in to the collective action and to authorize designated counsel to prosecute Claimant's FLSA claims on Claimant's behalf.

NOW, THEREFORE, in consideration of the terms and covenants contained herein and for other good and valuable consideration, the sufficiency of which is acknowledged, Claimant agrees as follows:

1. CONSENT TO JOIN

Claimant hereby consents to become a party plaintiff in the FLSA collective action for unpaid wages and/or overtime compensation. Claimant expressly authorizes that this written consent be filed with the Court as evidence of Claimant's consent to join the action. This consent applies to the period beginning through unless otherwise limited by Claimant in writing to counsel.

2. SCOPE OF CLAIMS

Claimant authorizes counsel to pursue all claims under the FLSA that arise from Claimant's employment with Employer during the claim period specified above, including claims for unpaid minimum wages, unpaid overtime, liquidated damages, interest, and reasonable attorneys' fees and costs. Claimant's consent does not, by itself, constitute an admission of liability by Employer.

3. AUTHORIZATION OF COUNSEL

Claimant appoints Counsel Name: as Claimant's representative for the prosecution of these FLSA claims. Counsel is authorized to file the Consent to Sue on Claimant's behalf, to receive notifications and pleadings, to negotiate on Claimant's behalf, and to accept service of process related to this matter.

4. AUTHORIZATION TO OBTAIN RECORDS

Claimant authorizes Employer, former employers, payroll processors, and third parties to disclose and release to counsel and/or the Court any and all employment records, time records, payroll records, personnel files, tax documents, and other documents relevant to Claimant's employment and compensation. Claimant consents to counsel obtaining such records without further consent from Claimant.

5. STATUTE OF LIMITATIONS; TOLLING

Claimant understands that executing and filing this consent may toll the applicable statute of limitations for the FLSA claims referenced herein. Claimant acknowledges that counsel will take such steps as counsel deems appropriate to preserve Claimant's rights and that Claimant may be bound by procedural time limitations imposed by the Court.

6. NO WAIVER OF RIGHTS UNLESS APPROVED

Claimant acknowledges that by consenting to join this action Claimant does not waive any rights except as may be expressly set forth in a final settlement agreement approved by the Court. Any settlement of Claimant's claims will require Claimant's separate signature and, where required, Court approval.

7. WITHDRAWAL OR REVOCATION

Claimant understands that withdrawal of this consent after filing requires Court approval or agreement of the parties. Counsel may withdraw from representation in accordance with applicable rules of professional conduct and Court procedures; such withdrawal does not by itself operate to revoke this consent without Court approval.

8. NOTICES

All notices or communications required or permitted under this consent shall be provided to the contact information set forth above for Claimant and for counsel. Claimant agrees to keep counsel informed of any change of address or telephone number during the pendency of the litigation.

9. GOVERNING LAW

This Consent shall be governed by and construed in accordance with the laws of the United States, including the Fair Labor Standards Act, and by the laws of the State of to the extent state law is implicated.

10. ENTIRE AGREEMENT; SEVERABILITY; AMENDMENT

This document contains the entire agreement between Claimant and counsel as to Claimant's consent to join the FLSA collective action. If any provision of this Consent is held invalid or unenforceable, the remainder shall continue in full force and effect. This Consent may be amended only by a written instrument signed by Claimant and counsel.

ACKNOWLEDGMENTS

By signing below, Claimant certifies under penalty of perjury that the information provided in this Consent is true and correct to the best of Claimant's knowledge; that Claimant understands the contents of this Consent; and that Claimant knowingly and voluntarily consents to join the FLSA action described herein.

I consent to receive case-related notices and documents electronically at the email address provided above.

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