Online Wage Claim Form

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

Hourly Wage 2

Wages Earned 2

Wages Paid 2

Wages Still Owed 2

Hours Worked 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