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Online Wage Claim Form

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 contact the Wage and Hour Unit at the information below.

Wage and Hour Unit
Vermont Department of Labor
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

Please check all that apply

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 1

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

Was the Work Preformed In Vermont?
Pay Agreement
$
Pay Rate Per:
Pay Received
Method of Payment
Employment was Terminated Because:
I Signed Authorization for Other Payroll Deductions
My Employer Sets Regular Work Hours
I was/am Covered by a union Contract
Statement Certification
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.
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