POTTER HANDY LLP
I, Uber Technologies, Inc. ; as follows:
$
Expert and Mediation Expenses: $
Potter Handy LLP: $
If the check(s) is/are made out to me personally, I hereby authorize Mark D. Potter to endorse the check(s) on my behalf to be deposited in his client trust account for dispersal as described above.
TAX DISCLAIMER. I acknowledge and agree that I am responsible for consulting my own tax advisor as to the tax consequences associated with receipt of the settlement funds referenced herein.
PUBLIC BENEFITS DISCLAIMER. I acknowledge and agree that if I receive needs-based benefits such as – but not limited to - SSI (Supplemental Security Income), Medi-Cal or subsidized housing, my settlement may affect my eligibility for and/or could cause a lapse or termination of those benefits. Potter Handy LLP offers no advice regarding my reporting requirements and no assurances that adverse consequences will not occur with regard to my benefits. Further, Potter Handy LLP assumes no responsibility for any such requirements or consequences. By signing this authorization form I acknowledge and agree that any reporting obligations are my responsibility alone, and that any adverse consequences to me resulting from the receipt of the settlement funds will be the responsibility of, and borne entirely by, me.
