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
Business Information
Section 1- Complaint Basis
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
Week 2
Week 3
Week 4
Reimbursement Claim Information
Reimbursement Week 2
Reimbursement Week 3
Reimbursement Week 4
Improper Deductions Information
Deductions Week 1
Deductions Week 2
Deductions Week 3
Deductions Week 4
Unpaid Leave Claim Information
Leave Week 1
Leave Week 2
Leave Week 3
Leave Week 4
Section 3- Employment Agreement Information
$
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.

Printable Wage Claim Complaint Form