TLS - Simmons BIPA: Designated Agent Authorization (Individual)

DESIGNATED AGENT AUTHORIZATION (Individual)

Simmons BIPA (Biometric Information Privacy Act) Settlement Claim
Simmons v. Motorola Solutions, Inc., No. 2024-L-010142 (Circuit Court of Cook County, Illinois)
I, First Name* Last Name* hereby retain Tanvi K. Sheth of T.K. Sheth Law LLC d/b/a The Law Shed, and their team (“Attorney”), to investigate and, if appropriate, pursue claims on my behalf in connection with the Simmons BIPA (Biometric Information Privacy Act) Settlement..

If the Settlement Administrator later requires a Taxpayer Identification Number for payment or tax reporting, I agree to provide it via a secure IRS Form W-9 upon request.
I grant a limited power of attorney to Attorney for the purpose of executing all documents and papers that I would execute relating to the Simmons BIPA Settlement Claim. This limited power of attorney includes the authority to request any records necessary to support my application. It also includes the authority to use my signature, including an image of my signature (provided below).

I authorize and instruct Attorney to use this limited power of attorney to:
(i) direct third-party payors to send all gross recovery payments to the Attorney; and
(ii) endorse my name to any checks or other instruments payable to me and take all other actions deemed appropriate by the Attorney in order to receive gross recovery payments into a trust account maintained by Attorney for the benefit of their clients.
Name*

First NameLast Name
Signature*

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Email*
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Date*

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File Upload: Hand-written/wet signature*

Hand-written/Wet Signature: Draw your signature on a clean paper and then take a picture and upload here
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File Upload: Initials Image*

Hand-written/Wet Initials: Write your initials on a clean paper and then take a picture and upload here
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File Upload: Valid Government Issued ID (Front)*

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File Upload: Valid Government Issued ID (Back)*

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DESIGNATED AGENT AUTHORIZATION (Individual)