Indicates required field Attorney Representation Agreement ATTORNEY REPRESENTATION AGREEMENT - (SHOPKO) It is hereby agreed that the firm of OUTTEN & GOLDEN LLP (hereinafter "ATTORNEYS"), shall represent the undersigned (hereinafter "CLIENT") for purposes of investigating whether to file an individual and/or class claim for unpaid severance and similar entitlements (“Unpaid Severance”) under applicable laws against SHOPKO (Specialty Retail Shops Holding Corp.), its affiliates and or any related entity which may also be liable. If ATTORNEYS and CLIENT agree to file an Unpaid Severance class claim, the following provisions will apply: 1. ATTORNEYS shall undertake and use their best efforts to obtain certification of the class of which CLIENT is a member in the action to be filed by ATTORNEYS on behalf of CLIENT, and all other similarly situated employees. 2. ATTORNEYS shall seek appointment by the Court as class counsel, and agree to undertake the representation of all members of the class that may be certified by the Court. 3. If the action is certified as a class action, and if a monetary recovery or other relief is obtained for the plaintiff class, either by settlement or judgment, ATTORNEYS will apply to the Court for reimbursement of their costs and payment of their fees by defendant(s) in addition to, or from, such recovery or relief. The Court has authority and discretion to fix the fee at the level it determines to be reasonable. CLIENT will retain his or her right, as a class member, to approve, oppose, or comment upon any proposed settlement of all or part of the class action, and to approve, oppose, or comment upon any application for reimbursement of costs and award of attorneys' fees made therein by ATTORNEYS. 4. If the action is not certified as a class action, or if events occur that make the case no longer suitable in the view of the ATTORNEYS, ATTORNEYS may withdraw as counsel for CLIENT. If that happens, ATTORNEYS will assist CLIENT to find counsel acceptable to CLIENT to represent CLIENT on an individual basis. 5. If the action is not certified as a class action, and if ATTORNEYS continue to represent CLIENT on an individual basis, no settlement shall be made therein by ATTORNEYS without the authorization of CLIENT. If the action is not certified as a class action, ATTORNEYS will receive the greater of (a) one-third (33 1/3%) of the net settlement proceeds, if any, or forty percent (40%) of judgment proceeds, if any, or (b) the full amount of any court-awarded attorneys' fees. For these purposes, "net proceeds" means the gross pre-tax recovery (including any award of attorneys' fees and the value of any benefits received) less any unrecovered disbursements. The fee set forth in this Agreement is not set by law, but is negotiable between ATTORNEYS and CLIENT. 6. CLIENT understands that ATTORNEYS will advance all legal, investigative and trial costs (hereinafter "disbursements") necessary for prosecution of CLIENT'S claims at their sole expense (to the extent applicable law and ethics rules allow), and will not bill or charge CLIENT for any costs. 7. ATTORNEYS' compensation shall not exceed any limits imposed by law. The contingent percentage of recovery set forth in this agreement is not set by law, but is negotiable between ATTORNEYS and CLIENT prior to signing this agreement. ATTORNEYS maintain an errors and omissions insurance coverage applicable to services contracted to be provided under this agreement. 8. In the absence of a certified class, CLIENT understands that no settlement of CLIENT'S monetary claims will be made without CLIENT'S approval. 9. In no event shall ATTORNEYS be entitled to payment of attorneys' fees by CLIENT if ATTORNEYS' efforts do not ultimately result in monetary recovery by CLIENT. 10. ATTORNEYS reserve the right to withdraw from the representation if CLIENT does not fulfill the terms and conditions of this Agreement, or if there is a difference of opinion between CLIENT and ATTORNEYS on a significant issue. CLIENT retains the right to discharge ATTORNEYS from individual representation for any reason whatsoever, provided, however, that CLIENT understands that class counsel serves by order of the court. In the event that CLIENT discharges ATTORNEYS as CLIENT'S individual representative, ATTORNEYS will be entitled to seek reimbursement from CLIENT in quantum meruit (the amount of the worth) for work actually performed by ATTORNEYS during the period of ATTORNEYS' representation of CLIENT. In such circumstances, ATTORNEYS shall have a lien for their compensation on CLIENT'S rights to recovery arising out of a wage collection claim. 11. CLIENT understands the effect of joint representation on ATTORNEY-CLIENT confidentiality. ATTORNEY-CLIENT communications are privileged and are protected against disclosure to a third party. Under this agreement, CLIENT understands that ATTORNEYS may represent and consents to ATTORNEYS representing multiple Plaintiffs. By entering into this agreement, CLIENT waives any right CLIENT may have to require that ATTORNEYS disclose to CLIENT any confidences ATTORNEYS have obtained from any other Plaintiff in connection with the subject matter of this agreement. 12. ATTORNEYS shall have the right to associate other attorneys at no additional expense to CLIENT. 13. Until the conclusion of this matter, CLIENT must preserve and maintain all documents and electronic records or files in your possession or control that relate to your employment in any way. These electronic records include, but are not limited to documents in paper format as well as electronic information stored in work or personal home computers, laptops, PDAs, thumb drives, cell phones, external hard drives, CDs, DVDs, voicemail, video, social networking websites, online email accounts, blogs or other storage media. Client Questionnaire - Company Please fill in the fields with the required information and check the accept box. CLIENT QUESTIONNAIRE Full Name First Middle Last Mailing Address Mailing Address City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Home or Cell Phone Number Work Phone Number Email Address Position/Title at Company If your job was assigned a particular level or band please state what that designation. Please state the store number or facility at which you worked: The address of the facility at which you worked Date of Hire Date of Termination Severance pay claim (if you did not receive it, answer these questions) State whether you received any plan, letter, promise, notice or statement offering severance pay in connection with your employment by Shopko If you received communications concerning severance pay, attach or describe any relevant communications or documents. When did you become aware that severance pay would not be paid, and please attach or describe any documents or messages. Retention pay claim (if you did not receive it, answer these questions) State whether you received any plan, letter, promise, notice or statement offering retention pay in connection with your employment by Shopko. Please state the manner in which you received information regarding the payment or non-payment of retention pay, and attach or describe any relevant communications or documents. Please state your basis for understanding that retention pay would not be provided. Vacation pay claim (if you did not receive it, answer these questions) State whether you received any plan, letter, promise, notice or statement offering vacation pay in connection with your employment by Shopko. Please state the manner in which you received information regarding vacation pay, and attach or describe any relevant communications or documents. Please state your basis for understanding vacation pay would not be paid, and attach or describe any relevant communications. Please state your gross annual or gross weekly salary: Besides your prospective severance, retention and vacation pay, what if any pay or benefits do you believe you have lost, or may lose, due to your termination (examples: medical or dental benefits, other paid time off, bonuses, 401k or deferred compensation, unreimbursed expenses, past due unpaid wages)? Attach Instructions Please attach a copy of any notice of your termination that you received. (By Mail) Please attach a copy of all documents you received from the bankruptcy court regarding Company and immediately notify us in the future if you receive any documents from the court. (By Mail) Please send any documents to: Outten & Golden LLP, 685 Third Avenue, 25th floor, New York NY 10017 or Fax 646-509-2070 Disclaimer Your Name Date Contact Preferences How would you like to be contacted? Email Phone Check all that apply.