In re Rent-Way, Inc. Securities Litigation 00-CV-323-Proof of Claim by dangerrous

VIEWS: 19 PAGES: 6

									                                      UNITED STATES DISTRICT COURT
                                FOR THE WESTERN DISTRICT OF PENNSYLVANIA
IN RE RENT-WAY SECURITIES LITIGATION                                     Case No. 00-323 Erie

This Document Relates To:                                                CLASS ACTION

         ALL ACTIONS.


                                                 PROOF OF CLAIM AND RELEASE

DEADLINE FOR SUBMISSION: OCTOBER 23, 2003.

IF YOU PURCHASED RENT-WAY, INC. COMMON STOCK DURING THE PERIOD FROM DECEMBER 10, 1998 THROUGH
OCTOBER 27, 2000, (the “CLASS PERIOD”), INCLUSIVE AND SUFFERED DAMAGES THEREBY YOU ARE A “CLASS
MEMBER” AND YOU MAY BE ENTITLED TO SHARE IN THE SETTLEMENT PROCEEDS. (EXCLUDED FROM THE CLASS
ARE DEFENDANTS IN THESE ACTIONS, MEMBERS OF THE IMMEDIATE FAMILIES (PARENTS, SPOUSES, SIBLINGS AND
CHILDREN) OF EACH OF THE INDIVIDUAL DEFENDANTS, ANY PERSON, FIRM, TRUST, CORPORATION, ENTITY IN
WHICH ANY DEFENDANT HAS A CONTROLLING INTEREST, THE OFFICERS, DIRECTORS, PARENTS, SUBSIDIARIES AND
AFFILIATES OF ANY CORPORATE DEFENDANT, AND THE LEGAL REPRESENTATIVES, HEIRS, SUCCESSORS IN
INTEREST OR ASSIGNS OF ANY SUCH EXCLUDED PARTY)

IF YOU ARE A CLASS MEMBER, YOU MUST COMPLETE AND SUBMIT THIS FORM IN ORDER TO BE ELIGIBLE FOR ANY
SETTLEMENT BENEFITS.

YOU MUST COMPLETE AND SIGN THIS PROOF OF CLAIM AND MAIL IT BY PRE PAID, FIRST CLASS MAIL, POSTMARKED
NO LATER THAN OCTOBER 23, 2003 TO THE FOLLOWING ADDRESS:

                                                   In re Rent-Way Securities Litigation
                                                          c/o Gilardi & Co. LLC
                                                           Claims Administrator
                                                          Post Office Box 5100
                                                        Larkspur, CA 94977-5100

YOUR FAILURE TO SUBMIT YOUR CLAIM BY OCTOBER 23, 2003 WILL SUBJECT YOUR CLAIM TO REJECTION AND
PRECLUDE YOUR RECEIVING ANY MONEY IN CONNECTION WITH THE SETTLEMENT OF THIS LITIGATION. DO NOT
MAIL OR DELIVER YOUR CLAIM TO THE COURT OR TO ANY OF THE PARTIES OR THEIR COUNSEL AS ANY SUCH
CLAIM WILL BE DEEMED NOT TO HAVE BEEN SUBMITTED. SUBMIT YOUR CLAIM ONLY TO THE CLAIMS
ADMINISTRATOR.

    1. I did ______, I did not ______ (check one) purchase common stock of Rent-Way, Inc. (“Rent-Way”) between December 10, 1998
and October 27, 2000, inclusive.

    2. By submitting this Proof of Claim, I state that I believe in good faith that I am a Class Member as defined above and in the Notice
Of Pendency Of Class Action Hearing On Proposed Settlement And Attorneys’ Fee Petition And Right To Share In Settlement Fund (the
“Notice”), or am acting for such person; that I am not a Defendant in the Class Action or anyone excluded from the Class; that I have read
and understand the Notice; that I believe that I am entitled to receive a share of the Net Settlement Fund; that I elect to participate in the
proposed Settlement described in the Notice; and that I have not filed a request for exclusion.

     3. I have set forth where requested below all relevant information with respect to each purchase of Rent-Way common stock during
the Class Period, and each sale, if any, of such securities.

     4. I have enclosed photocopies of the stockbroker’s confirmation slips, stockbroker’s statements, relevant portions of my tax returns
or other documents evidencing each purchase, sale or retention of the Rent-Way common stock listed below in support of my claim. IF
ANY SUCH DOCUMENTS ARE NOT IN YOUR POSSESSION, PLEASE OBTAIN A COPY OR EQUIVALENT DOCUMENTS
FROM YOUR BROKER OR TAX ADVISOR BECAUSE THESE DOCUMENTS ARE NECESSARY TO PROVE AND PROCESS
YOUR CLAIM.

    5.   I understand that the information contained in this Proof of Claim is subject to such verification as the Court may direct, and I
agree to cooperate in any such verification. I further agree and understand that if the proposed Settlement is approved by the Court and
becomes effective, all claims, demands, or causes of action against any or all of the Settling Defendants and the Released Parties which have
been or could have been asserted relating to the subject matter of the Litigation will be satisfied, discharged and extinguished forever.

    6. Upon the occurrence of the Effective Date (as defined in the Notice) my signature hereto will constitute a full and complete release,
remise and discharge by me or, if I am submitting this Proof of Claim on behalf of a corporation, a partnership, estate or one or more other
persons, by it, him, her or them, and by my, its, his, her or their heirs, executors, administrators, successors, and assigns, of each of the
“Settling Defendants” and “Released Parties” of all “Settled Claims,” as defined in the Notice.




                                                                          2
                                                                                                                 M ust be Postm arked
                                                                                                                 N o Later T han:
                       Official                                                                                  O ctober 23, 2003
                                                          U N ITED STA TES D ISTR IC T CO U RT
                        Office
                          Use                              FO R TH E W ESTER N D ISTRIC T O F
                         Only                                       PEN N SY LV A N IA

                                                            In re R ent-W ay Securities Litigation
                                                                                                                   RENT1
                                                                    C ase N o. 00-323 Erie
                                                          PR O O F O F C L A IM A N D R E L E A SE

                                                          Please Type or Print in the Boxes B elow

                                                               D o N ot U se R ed Ink O r Pencil
         7. Statem ent of C laim

 B eneficial O w ner's First N am e



 Last N am e




 R ecord O w ner's N am e (if different from B eneficial O w ner listed above)




Social Security N um ber                               Em ployer Identification N um ber                  C heck O ne:
                                                                                                             Individual     C orporation
                 -               -                or             -                                           Estate
                                                                                                             O ther: ___________
Telephone N um ber (D ay)                           Telephone N um ber (N ight)

                                     -                                            -
Em ail A ddress



         M ailing Inform ation
 A ddress 1


 A ddress 2


 C ity                                                                                State        Zip C ode

                                                                                                                        -
 Foreign Province                                                                       Foreign Zip C ode


 Foreign Country




                For C laim s
                                         PC       LS         BC1           D EF         LA TE
                Processing only
                                                                      3
 8.   I m ade the follow ing purchases of R ent-W ay com m on stock during the period D ecem ber 10, 1998 through O ctober 27, 2000,
      inclusive.


       P urchases

                                                                                                         A ggregate C ost          P roof O f
                          D ate(s) of Purchase                      N um ber of Shares              T o N earest W hole D ollar    P urchase
                         (L ist C hronologically)                       P urchased                 (exclusive of com m issions)   E nclosed?

              M      M        D   D          Y   Y   Y   Y
                                                                                                                                        Y
       1.                /             /                                                      $                                         N
                                                                                                                                        Y
       2.                /             /                                                      $                                         N
                                                                                                                                        Y
       3.                /             /                                                      $                                         N
                                                                                                                                        Y
       4.                /             /                                                      $                                         N
                                                                                                                                        Y
       5.                /             /                                                      $                                         N




 9.   I m ade the follow ing sales of R ent-W ay com m on stock during the period D ecem ber 10, 1998 through O ctober 27, 2000,
      inclusive:

            S ales

                                                                                                           N et P roceeds          P roof O f
                              D ate(s) of Sale                           N um ber of                T o N earest W hole D ollar       S ale
                         (L ist C hronologically)                        S hares Sold              (exclusive of com m issions)   E nclosed?

             M       M        D   D         Y    Y   Y   Y
                                                                                                                                          Y
       1.                /             /                                                       $                                          N
                                                                                                                                          Y
       2.                /             /                                                       $                                          N
                                                                                                                                          Y
       3.                /             /                                                       $                                          N
                                                                                                                                          Y
       4.                /             /                                                       $                                          N
                                                                                                                                          Y
       5.                /             /                                                       $                                          N




10. A t the close of business on O ctober 27, 2000, I still ow ned the follow ing num ber of R ent-W ay
    shares:

  If you require additional space beyond w hat has been provided, attach copies of this page as necessary. Sign and print your nam e
  on each additional page.



                                           Y O U M U ST R E A D A N D SIG N T H E R E L E A SE O N P A G E 5.

                                                                           4
                                                            11. Sub stitute F orm W -9
        R equest for T axpayer Identification N um ber:

       E nter taxpayer identification num ber below for the B eneficial O w ner(s). For m ost individuals, this is your Social Security
   N um ber. T he Internal R evenue Service ("I.R .S.') requires such taxpayer identification num ber. If you fail to provide this
   inform ation, your claim m ay be rejected.

                Social Security N um ber                                                E m ployer Identification N um ber

                               -             -                               or                    -
                 (for individuals)                                                      (for estates, trusts, corporations, etc.)
                                                                 12. C ertification

      U N D E R T H E P E N A L T IE S O F P E R JU R Y , I (W E ) C E R T IF Y T H A T A L L O F T H E IN F O R M A T IO N P R O V ID E D
  O N T H IS P R O O F O F C L A IM F O R M IS T R U E , C O R R E C T A N D C O M P L E T E .

     I (W e) certify that I am (w e are) N O T subject to backup w ithholding under the provisions of Section 3406 (a)(1)(c) of the
Internal R evenue C ode because: (a) I am (W e are) exem pt from backup w ithholding, or (b) I (W e) have not been notified by the
I.R .S. that I am (w e are) subject to backup w ithholding as a result of a failure to report all interest or dividends, or (c) the I.R .S. has
notified m e (us) that I am (w e are) no longer subject to backup w ithholding.

N O T E : If you have been notified by the I.R .S that you are subject to backup w ithholding, please strike out the language that you
are not subject to backup w ithholding in the certification above.

                                                   Signature of C laim ant (If this claim is being m ade on behalf of Joint C laim ants,
                                                   then each m ust sign)


                                                    _________________________________________________________________
                                                   (Signature)


                                                   _________________________________________________________________
                                                  (Signature)


                                                   _________________________________________________________________
                                                   D ate



 T H IS PR O O F O F C L A IM M U ST B E SU B M IT T E D N O L A T E R T H A N O C T O B E R 23, 2003 A N D M U S T B E M A IL E D T O ;

                                                    In re R ent-W ay Securities L itigation
                                                            c/o G ilardi & C o. L L C
                                                             C laim s A dm inistrator
                                                             Post O ffice B ox 5100
                                                          L arkspur, C A 94977-5100

    A Proof of C laim received by the C laim s A dm inistrator shall be deem ed to have been subm itted w hen posted, if m ailed by
O ctober 23, 2003, and if a postm ark is indicated on the envelope and it is m ailed first class postage prepaid, and addressed in
accordance w ith the above instructions. In all other cases, a Proof of C laim shall be deem ed to have been subm itted w hen actually
received by the C laim s A dm inistrator.

     If you w ish to be assured that your Proof of C laim is actually received by the C laim s A dm inistrator then you should send it by
certified m ail, return receipt requested. N o acknow ledgm ent w ill be m ade as to the receipt of claim form s. Y ou should be aw are
that it w ill take a significant am ount of tim e to process fully all of the Proofs of C laim and to adm inister the Settlem ent. T his w ork
w ill be com pleted as prom ptly as tim e perm its, given the need to investigate and tabulate each Proof of C laim . Please notify the
C laim s A dm inistrator of any change of address.




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TH IS P A G E IN TE N TIO N A L LE FT B LA N K




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