Vermont Official State Website

Online Wage Claim Form

Please Note:
You cannot file a claim for wages more than two years after the date they are due.

If you need assistance completing this form, please feel free to contact us!

WAGE and HOUR PROGRAM
63 Pearl Street
Burlington, VT 05401-4331
Telephone: 802-951-4083 FAX: 802-863-7655
Email: Labor.WageHour@vermont.gov

Your Information

First Name *

Last Name *

Email Address *

Telephone *

Address *

Address Line 2

City *

State *

Postal Code *

Business Information

Name of Business *

Business Address *

Business Address Line 2

Business City *

Business State *

Business Postal Code *

Employer Telephone *

Employer Email Contact

Section 1- Complaint Basis

Please check all that apply *

Unpaid Wages

Minimum Wage Violation

Unpaid Overtime

Earned Sick time Violation

Improper Deductions from Wages

Failure to Provide Proper Wage Statement with each Wage Payment

Unlawful Child Labor

Failure to Accommodate Nursing Mother

Other

Please Explain Your Complaint or Concern Below *

If this is NOT a Claim for Wages you may STOP here! Please Sign and Date and click the "Submit" Button at the end of the form.

Section 2 Wage Claim Information

Week 1

Payment Due Date

Hours Worked 1

Hourly Wage 1

Wages Earned 1

Wages Paid 1

Wages Still Owed

Week 2

Payment Due Date 2

Hours Worked 2

Hourly Wage 2

Wages Earned 2

Wages Paid 2

Wages Still Owed 2

Week 3

Payment Due Date 3

Hours Worked 3

Hourly Wage 3

Wages Earned 3

Wages Paid 3

Wages Still Owed 3

Week 4

Payment Due Date 4

Hours Worked 4

Hourly Wage 4

Wages Earned 4

Wages Paid 4

Wages Still Owed 4

Reimbursement Claim Information

Reimbursement Week 1

Due Date 1

Unpaid Amount 1

Reimbursement Week 2

Due Date 2

Unpaid Amount 2

Reimbursement Week 3

Due Date 3

Unpaid Amount 3

Reimbursement Week 4

Due Date 4

Unpaid Amount 4

Improper Deductions Information

Deductions Week 1

-Due Date 1

-Unpaid Amount 1

Deductions Week 2

-Due Date 2

-Unpaid Amount 2

Deductions Week 3

-Due Date 3

-Unpaid Amount 3

Deductions Week 4

-Due Date 4

-Unpaid Amount 4

Unpaid Leave Claim Information

Leave Week 1

--Due Date 1

--Unpaid Amount 1

Leave Week 2

--Due Date 2

--Unpaid Amount 2

Leave Week 3

--Due Date 3

--Unpaid Amount 3

Leave Week 4

--Due Date 4

--Unpaid Amount 4

Section 3- Employment Agreement Information

Name of Employer

Direct Supervisor

Type of Work Preformed

Was the Work Preformed In Vermont?

Yes

No

Start Date of Employment

End Date of Employment

Pay Agreement

Oral

Contract (provide a copy)

Written Policy (provide copy)

Rate of Pay $

Pay Received

Weekly

Bi-Weekly

Monthly

Other

Method of Payment

Check

Cash

Direct Deposit

Other

Employment was Terminated Because:

I Quit

I was Discharged

I'm Still Employed

I Signed Authorization for Other Payroll Deductions

Yes

No

Unsure

My Employer Sets Regular Work Hours

Yes

No

I was/am Covered by a union Contract

Yes

No

Unsure

Statement Certification *

Yes, I certify my Statement is True.

By checking this box, I hereby certify that, to the best of my knowledge, this statement is true. I understand that a copy of this claim, and any materials that I submit to the Wage and Hour Program relative to this claim, will be forwarded to my employer and/or employer's representative.

Signature (Please Type Your full name) *

Date Signed: *

Printable Wage Claim Complaint Form

Click for a Printable form

Contact Information

Vermont Department of Labor
5 Green Mountain Drive
P.O. Box 488
Montpelier, 05601-0488
(802) 828-4000

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