Legal Labor Claim Form

Legal Labor Claim Form

Claimant Name:    Claimant Address:

Employer/Respondent Name:    Employer Address:

RECITALS

WHEREAS, Claimant is or was employed by Employer in the position of beginning on and ending on (if applicable);

WHEREAS, Claimant alleges that Employer engaged in employment practices that violate Claimant's rights under applicable labor laws, including but not limited to wrongful termination, unpaid wages, discrimination, retaliation, or failure to accommodate, as described in this form; and

WHEREAS, Claimant seeks administrative and civil remedies as set forth below and requests that Employer provide factual responses and any relief required by law.

NOW, THEREFORE, Claimant submits the following statements, factual allegations, and demands for relief to document the claim and to provide Employer notice of the matters in dispute.

1. CLAIM SUMMARY

2. FACTUAL ALLEGATIONS

Date(s) of Incident(s):    Location(s):

3. RELIEF SOUGHT

Claimant seeks the following relief (check all that apply):

Back pay    Reinstatement    Compensatory damages

Punitive damages    Injunctive relief    Attorneys' fees and costs

4. WITNESSES AND EVIDENCE

5. REPRESENTATION

Is Claimant represented by counsel?    Yes    No

6. CALCULATION WORKSHEET

7. NOTICES

All notices and communications relating to this claim should be sent to the addresses provided above or to the following contact information for Claimant and Employer.

8. CERTIFICATION

I, the undersigned Claimant, declare under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge, information, and belief. I understand that knowingly submitting false statements or material omissions may subject me to civil or criminal penalties as provided by law.

9. LEGAL PROVISIONS

Governing Law: This claim and any disputes arising under or relating to it shall be governed by and construed in accordance with the substantive laws of the state identified by the parties' principal addresses, without regard to its conflict of laws principles.

Entire Agreement: This form, together with any attachments and written responses, constitutes the entire statement of Claimant's factual allegations and requested relief as of the date signed and supersedes any prior written or oral statements regarding the matters asserted herein.

Severability: If any provision of this form is determined to be invalid, illegal, or unenforceable, the remainder of the form shall remain in full force and effect and shall be construed so as to effectuate the intent of the parties as nearly as possible.

Amendments; Waiver: Any amendment to this claim must be made in writing and signed by the party making the amendment. The failure of any party to enforce a provision of this form shall not be construed as a waiver of such provision or of the right to enforce such provision in the future.

Counterparts and Electronic Signatures: This form may be executed in counterparts, each of which shall be deemed an original, and signature pages delivered by electronic transmission shall be treated as originals for all purposes.

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