Step 1 of 2 - Claim Information 50% EEOC v. AMTCR (McDonald’s) Claim Form If you are or were employed by AMTCR, Inc., AMTCR Nevada, LLC, AMTCR, California, LLC, White Bluff, Inc., Gamble Oak, Inc., or Rock Basin, LLC dba McDonald’s (collectively the “AMTCR Companies”) and believe you were subject to sexual harassment and/or a sexually hostile work environment at any time between January 1, 2017 and January 5, 2023, you may be eligible to receive money from the U.S. Equal Employment Opportunity’s (“EEOC” or “Commission”) settlement if the EEOC determines you were a victim of sexual harassment in violation of Title VII of the Civil Rights Act of 1964 during your employment with McDonald’s. To be considered for inclusion in the settlement, you must complete and return this Claim Form by October 10, 2023 to the Claims Administrator. The EEOC will use this information to determine whether you are eligible for money from the settlement and, if so, how much. We may contact you to gather additional information when determining your eligibility to receive money from the settlement. Once the EEOC makes a determination, the EEOC or the Claims Administrator will communicate with you about whether you are eligible and, if you are, what additional steps will be required in order to obtain any monetary relief. Please be sure to keep the EEOC and Claims Administrator informed about any changes to your contact information. If the EEOC or Claims Administrator is unable to reach you, it may affect your ability to recover any money you are deemed eligible to receive.ClaimFormNoClaimant ID* Name* First Last Date of Birth* Month Day Year Social Security No.*Home Address* Street Address Address Line 2 City State / Province / Region Zip Code Cell Phone*Home Phone*Email Address* 1. Provide the start and end date of your employment with one or more of the companies listed above dba McDonald’s.Company Name* Start Date* End Date* If you are still working at the company, enter 'Present'.Company Name (2) Start Date (2) End Date (2) Company Name (3) Start Date (3) End Date (3) 2. At any time between January 1, 2017 and January 5, 2023, did you personally experience and/or witness any of the following behaviors by any company employee while you were employed there? Read the list of behaviors below and select the response options that best describe what you experienced and/or witnessed during your employment there. Select all that apply.q2Checkboxes Unwanted or unwelcome sexual verbal advances, suggestive stories or discussions about sex, crude sexual remarks, sex-based comments or sex-based offensive remarks. Staring or leering, visual displays of materials with content that is offensive to a particular sex or sexual in nature, or sexual or sexually suggestive gestures. Unwanted or unwelcome sexual attention including, but not limited to, , attempts to pursue or establish a sexual relationship, or repeated requests for drinks or dinner despite rejection. Unwanted or unwelcome touching, rubbing, or other intentional physical contact, including attempts to touch or brush up against sensitive or intimate areas, kissing, and sexual intercourse. Pressure to engage in sexual behavior, threats for not cooperating sexually, fear of poor treatment or adverse employment actions absent sexual cooperation, or consequences for refusing sexual attention or attempts. Other unwanted or unwelcome behavior due to sex, such as being forced to work in a sexually hostile workplace: Other unwanted or unwelcome behavior explanationPlease explain other unwanted or unwelcome behavior in the space provided.3. Were any of the actions you experienced or witnessed in Question #2 by:q3checkboxes A manager or supervisor? A non-management/non-supervisory employee? Both a manager/supervisor and a non-management/non-supervisory employee? If you marked any of the options in Question #2, for each incident, describe what type of unwanted or unwelcome behavior you experienced and, if you know, the frequency of the incidents and any dates you can recall, and the identity of the alleged harasser(s) and their job title(s). If you experienced more than three separate incidents, please provide the same information for the additional incidents on Attachment A, which provides additional pages.Incident #1:Description of the behaviorFrequency of the behavior: Dates: Identity and job titles of the alleged harasser(s): Any additional information you wish to provide about this incident:Incident #2:Description of the behaviorFrequency of the behavior: Dates: Identity and job titles of the alleged harasser(s): Any additional information you wish to provide about this incident:Incident #3:Description of the behaviorFrequency of the behavior: Dates: Identity and job titles of the alleged harasser(s): Any additional information you wish to provide about this incident:4. Did you complain about the incidents you described in Question #3 to anyone in the company? (If you answer “no” to this question, please skip to Question #13).q4 option Yes No 5. If you answered “yes” to Question #4, which incidents that you described in Question #3 did you complain about? Describe the first complaint you made including whether the complaint was in writing or verbal, who the complaint was made to, when you made the complaint, the conduct or incident(s) that you complained about, and the response to your complaint, if any. Describe any subsequent complaints in Attachment A, which provides additional pages.q5 response6. Was the person you complained to a supervisor or manager?q6 option Yes No 7. Did you complain to someone in Human Resources (HR)?q7 option Yes No 8. Provide the name of the person or people you complained to, if you can remember.Full Name Job Title Full Name (2) Job Title (2) Full Name (3) Job Title (3) 9. When did you complain? Be as specific as you can.Date(s) 10. Did the objectionable or offensive behavior change after you complained?q10 option Yes, the behavior stopped. No, there was no difference in behavior. Yes, the behavior improved (for example, became less frequent or less offensive). The behavior improved for a period of time, but then returned. The behavior worsened (for example, became more frequent or more offensive). 11. What actions were taken by company management as a result of your complaint? Select all that apply.q11 checkboxes My complaint was addressed to my satisfaction The rules on harassment were explained to everyone Someone talked to the offender(s) to ask them to change their behavior The offender(s) was/were moved or reassigned to limit contact with me My workstation, schedule, duties were changed to limit contact with the offender(s) The offender(s) was/were terminated I do not know what happened The person I told took no action The offender(s) took action against me for complaining (for example, they threatened you) I was encouraged to drop the issue I was penalized for bringing it up (for example: loss of privileges, denied opportunities/training, assigned less favorable job/project, excluded from meetings or social activities, more closely scrutinized, moved or reassigned, issued discipline) Other: q11 Other explanationProvide other detail action taken by company management as a result of your complaint in the space above.12. If there is anything else you would like to share about what happened following your complaint(s), describe in the space below.q12 response13. If you answered “no” to Question #4, why did you decide not to complain? Select all that apply.q13 checkboxes Did not think it was serious enough Other actions resolved the situation satisfactorily Thought it would make my work situation unpleasant Did not think anything would be done Thought the situation would not be kept confidential Did not want to hurt the person who had bothered me Thought it would adversely affect my career Was too embarrassed Thought I would be blamed Did not think I would be believed Supervisor was not supportive Did not know what actions to take or how to take them Would take too much time or effort Someone else complained about the same issue Other: q13 other responseDAMAGES14. If you are no longer employed by one of the companies listed above, select the reason for your employment ending:q14 checkboxes Forced to Quit Mutual Agreement Voluntary Quit Involuntary Termination Other: q14 other response15. Do you believe that the reason your employment ended was related to the sexual harassment and/or sexually hostile work environment you experienced?q15 option Yes No 16. If you answered “yes” to Question #15, explain why you believe the ending of your employment was related to the sexual harassment and/or sexually hostile work environment you experienced.q16 response17. If you were forced to quit, was your resignation caused by the sexual harassment and/or sexually hostile work environment?q17 option Yes No 18. If you answered “yes” to question #17, please explain why you believe your resignation was caused by sexual harassment and/or sexually hostile work environment in the space below.q18 response19. As a result of the sexual harassment and/or sexually hostile work environment, did you experience any negative emotions such as anger, embarrassment, sadness, stress, or confusion?q19 option Yes No 20. If you answered “yes” to Question #19, describe the negative emotions you experienced and how they affected you.q20 response21. If you answered “yes” to Question #19, did you receive medical treatment or counseling because of the negative emotions?q21 option Yes No ATTACHMENT AProvide any additional information here:Upload any additional information here. Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 16 MB, Max. files: 5. Typed signature* Signature Acknowledgment* I state that the above answers are correct to the best of my knowledge. I do not know of any reason that I am ineligible to participate in this claims process or receive monetary relief from the Settlement fund in this matter. 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