Wage Claim Form

WAGE CLAIM FORM

This Wage Claim Form (the Claim) is submitted by Claimant Name: (hereinafter "Claimant") against Employer Name: (hereinafter "Employer") on this date: . Claimant's current mailing address: . Employer principal place of business: .

RECITALS

WHEREAS, Claimant was employed by Employer in the capacity of from through .

WHEREAS, Claimant asserts that Employer failed to pay wages and other compensation due for the period beginning and ending , inclusive (the Claim Period), as further described in this form.

WHEREAS, Claimant seeks recovery of unpaid wages, overtime, penalties, interest, and any other remedies permitted by applicable law.

NOW THEREFORE, for the purposes of initiating a formal wage claim by submission of this form, the parties state and agree to the following.

1. CLAIM SUMMARY

Unpaid regular wages    Unpaid overtime    Commissions

Tips    Accrued vacation/sick pay    Unreimbursed expenses

2. ITEMIZED WAGE CALCULATION

Provide an itemized calculation showing dates, hours, rates, amounts owed, and basis for each component of the claim. Attach supporting paystubs, time records, commission statements, and correspondence where available.

3. LEGAL BASIS AND REMEDIES

Claimant alleges that Employer's failure to pay wages arose from the following legal basis (select all that apply and provide explanation):

Claimant asserts entitlement to the principal amount claimed, liquidated damages, statutory penalties where applicable, pre-judgment interest at the legal rate, reasonable attorneys' fees and costs, and any other remedies authorized by law.

4. INVESTIGATION AND DISCLOSURES

Claimant hereby authorizes Employer and the reviewing authority to examine payroll records, timecards, personnel files, and other documents necessary to verify the Claim. Claimant further certifies that the information provided in this form and in any attachments is true and correct to the best of Claimant's knowledge.

5. REPRESENTATIONS, WARRANTIES, AND CERTIFICATION

Claimant represents and warrants that: (a) Claimant has not previously released the claims herein in a binding written agreement; (b) the facts set forth in this Claim are accurate and within Claimant's knowledge; and (c) Claimant will promptly provide additional documentation upon request.

Certification: Under penalty of perjury, Claimant certifies that the information provided in this form and any attachments is true and correct.

6. NOTICES

All notices or communications required or permitted under this submission shall be in writing and delivered to the addresses provided above. Notice shall be effective upon personal delivery or three (3) business days after deposit in the United States mail, postage prepaid, addressed to the party's mailing address.

7. MISCELLANEOUS PROVISIONS

Governing Law: This Claim and any dispute arising from it shall be governed by the substantive laws of the state in which the work was performed, without regard to conflict of law principles, except where a controlling statute provides otherwise.

Entire Agreement: This form, together with any attachments, constitutes the entire written statement of the Claim as submitted and supersedes any prior written or oral statements relating to the subject matter of this Claim.

Severability: If any provision of this Claim is held unenforceable, the remainder of the Claim shall remain in full force and effect.

Amendments and Waiver: Any amendment or waiver to this submission must be in writing and signed by the party to be bound. Failure to insist upon strict compliance with any provision shall not constitute a waiver of that provision.

8. REMEDY ELECTION

Claimant elects to pursue relief by initiating the wage claim process and does not, by submission of this form, waive any rights to pursue additional administrative or judicial remedies where permitted by law.

ADDITIONAL INFORMATION

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