Iowa Wage Claim Form

Iowa Wage Claim Form

IMPORTANT - READ CAREFULLY

The Division of Labor Services enforces the Iowa Wage Payment Collection and the Iowa Minimum Wage Laws.

Enclosed is a Claim for Wages Form you should fill out completely. Be sure to include the amount of the claim, sign, date and return the form to this office.

Our Address Is: Division of Labor Services
1000 East Grand Avenue
Des Moines, Iowa 50319-0209

Your claim will not be accepted if either of the two following items applies to your situation:

• The amount of your claim exceeds $5,000.00
• The work for which you are seeking payment was not done in Iowa

Under the law, our office may not accept a complaint for unpaid wages after one year from the date the wages became due and payable. Therefore, do not include in your claim any amount that became due and payable prior to one year from the date that you return the enclosed complaint form to our office.

In order for our office to effectively and efficiently investigate your claim, the form must be completed in full and in detail. Also, if you are paid any or all of your wages from your employer after you have returned your Claim for Wages Form, you are required to notify this office within three days of receipt of the payment.

Also, you should be aware, once this office receives and accepts your Claim for Wages Form, a letter will be sent to your employer. In that letter, the employer is given fourteen days to respond with information and documentation.

Wage Claim Worksheet

Employer:

Docket # (Division of Labor Entry):

Wages or Salary

Total Claim $:

I certify the above is true according to my best information and belief.

Print Name:

Sign Name:

Date:

Claim for Wages

Wages Claimed

1. Total amount still owed to you (do not deduct taxes or social security):

2. My claim includes the following (check the box next to all that apply and provide the necessary information provided for each)

Minimum Wage

Unpaid Wages and/or Salary

Provide the beginning and ending dates for which wages and/or salary is owed: to

Wages: Total number of hours worked and not paid and/or underpaid at $ per hour

Salary: Total number of weeks worked and not paid and/or underpaid at $ per

Unpaid Commissions

The following percentage should have been received: %

Total amount of sales, services, etc. provided but no commissions were received (do not deduct taxes or social security):

What was the employer’s agreement for time of payment? Explain in detail:

Work for unpaid commissions was performed during the following dates:

Illegal Deductions

An illegal deduction(s) was taken for the following reason(s):

Deduction was made on the following: Date OR Pay Period to

Vacation Pay

What is the employer’s policy to pay vacation or personal time off at the end of employment? Explain in detail:

Bonus

Explain in detail:

Other

Claim is not included in the options provided above and/or there is additional information to be included. Explain in detail:

Employment Agreement

Note: Be sure your social security number is in the top left corner on the front of this form.

3. I was hired by:

4. My direct supervisor was:

5. Type of work I performed:

6. Work was performed in Iowa: Yes No

7. Starting date of employment:

8. Ending date of employment:

9. Pay agreement: Oral Contract (provide copy) Written Policy (provide copy)

10. Rate of pay: Per: Hour Week Month Other If Other, explain:

11. Received pay: Weekly Bi-Weekly Monthly Other If Other, explain:

12. Method of payment: Check Cash Other If Other, explain:

13. Employment was terminated because: I quit Yes No I was discharged Yes No

Explain in detail:

14. I have filed for unemployment insurance since leaving this employer: Yes No

15. The employer is still in the same business: Yes No

If No, explain in detail:

16. My employer deducted social security and withholding taxes: Yes No

If No, explain in detail reasons why with an attached explanation.

17. I signed authorization for other deductions: Yes No

If Yes, explain in detail and attach an explanation.

18. My employer set regular work hours: Yes No

19. I was covered by a union contract: Yes No

If Yes, contact your union representative before filing this claim with the Division of Labor.

20. I have retained an attorney or filed a lawsuit regarding this matter: Yes No

If Yes, do not file this claim until you have discussed it with the attorney and provide the following information about the attorney:

First and Last Name: Phone Number: Name of County where Lawsuit is Filed:

Address: City: State: Zip Code:

21. I am willing to testify in court: Yes No

If No, explain in detail:

Claimant’s Signature:

Date Signed:

I hereby certify, under penalty of perjury, that the information I have provided on this form is true according to my best information and belief.

I assign in trust this claim and all penalties accruing because of non-payment, and liens securing them, to the Labor Commissioner. This assignment shall become effective upon a determination by the Commissioner that I have an enforceable claim. I authorize the Commissioner to settle this claim. I authorize the Commissioner to receive payment for this claim, and authorize such payment to be mailed to me unless I have made a different arrangement with the Commissioner.

I understand that I must cooperate as required by the Commissioner, and it is my responsibility to provide sufficient information to prove the claim due. I understand that there is no guarantee that the Commissioner will accept my claim, and no guarantee that the Commissioner will be able to collect upon it.