Pacific Telesis Group Salaried Pension Plan ATB Benefit Miscalculation Litigation Yes, I am interested in knowing more about this case. Personal Information: 1. Name: _________________________________ 2. Address: _______________________________ _______________________________ 3. E-mail: _________________@_____________ 4. Telephone: Home (___) ____ -- ________ Cell (___) ____ -- ________ Employment History: 5. Please choose one of the following: (a) I am current employee (b) I am a retiree (If so, what was your date of retirement): ___/___/_____ 6. Were you a participant in the Pacific Telesis Group Pension Plan for Salaried Employees? Check one: Yes __ No __ If you know, At the time of your termination of employment, were you eligible to receive an Alternative Transition Benefit (“ATB”)? Check one: Yes __ No __ 7. Information about the dates you were employed by a subsidiary or affiliate of Pacific Telesis? (a) Did you terminate your employment with Pacific Telesis or affiliated company after March 22, 1996? (b) After your first termination, were you subsequently rehired on or before October 31, 1997? (c) After you were rehired, did you work at least 5 additional years? If the answer to (a), (b) and (c) are yes, please provide the following information: First Start Date: ___/___/_____ First Termination Date: ___/___/_____ Rehire Date: ___/___/_____ Second Termination Date: ___/___/_____ 8. Identify the subsidiaries or affiliates of Pacific Telesis that you worked for? (Check as many as you worked for) Pacific Telesis Group ___ Pacific Bell Information Services ___ Pacific Telesis Group-Washington ___ PacTel Finance ___ Pacific Telesis Legal Group ___ Pacific Bell Internet Services ___ Pacific Bell ___ Pacific Bell Network Integration ___ Pacific Bell Directory ___ Pacific Bell Communications ___ Nevada Bell ___ Pacific Bell Extras ___ Telesis Technologies Laboratory ___ Pacific Telesis Enterprises ___ Pacific Bell Mobile Services ___ Pacific Bell Development Company ___ Telesis Enhanced Services ___ Pacific Telesis Electronic Publishing Services ___ Pacific Telesis Video Services ___ Other (please list): _________________ 9. Do you have documents such as a Summary Plan Description (SPDs), Plan Documents, Participation Statements, etc. (You do not need to have such information) ? ___ Yes ___ No Thank you for taking the time to complete this form. Please mail or email this form to: Gail Regina, Paralegal Cohen Milstein Sellers & Toll PLLC 1100 New York Avenue, Suite 500 Washington DC 20005 [email protected] 2 .