WOMEN'S HURON VALLEY CLASS ACTION LITIGATION

Economic Damages Form

1.       Your name:  _____________________________________

2.       Date of hire by MDOC:  _____________________________________

3.       Date of assignment to WHV:  _____________________________________

PRE-2009 W-2 INFORMATION

4.       W-2 amount for years before 2009:

          2002 $___________________________

          2003 $___________________________
          2004 $___________________________
          2005 $___________________________
          2006 $___________________________
          2007 $___________________________
          2008 $___________________________

 5.       Average over reported years $___________________________

2009-2015 W-2 INFORMATION

6.       W-2 amount for 2009-2015

          2009 $___________________________
          2010 $___________________________
          2011 $___________________________
          2012 $___________________________
          2013 $___________________________
          2014 $___________________________
          2015 $___________________________

 7.       Average over seven years $___________________________

8.       Difference between Pre-2009 and 2009 forward average

Line 5 – Line 7:  $___________________________