Wage Theft Claim Form

Wage Theft Claim Form

This Wage Theft Claim Form is submitted by Claimant Name: (hereinafter "Claimant") against Respondent Name: (hereinafter "Respondent"). Submission Date:

RECITALS

WHEREAS, Claimant alleges that during the period of employment set forth below, Respondent failed to pay wages and other compensation due under applicable wage-and-hour laws and contractual agreements; and

WHEREAS, Claimant seeks to present an itemized claim for unpaid regular wages, overtime, statutory penalties, interest, and any other recovery provided by law; and

WHEREAS, the parties desire to record the facts and demands in a written claim form to preserve remedies and to facilitate administrative or informal resolution procedures.

NOW, THEREFORE

The Claimant states the following facts, claims, and demands and certifies under penalty of perjury that the information provided is true and correct to the best of Claimant's knowledge.

1. EMPLOYMENT DETAILS

Exempt from overtime under applicable law (check if applicable)

2. STATEMENT OF CLAIM — ITEMIZED ALLEGED VIOLATIONS

Provide a chronological, itemized statement of each pay period or incident for which wages, overtime, or other compensation is claimed. If additional space is required, attach a separate page and indicate "See attached" below.

1. Pay Period: Start: End: Hours Unpaid: Amount Claimed: $

2. Pay Period: Start: End: Hours Unpaid: Amount Claimed: $

3. Pay Period: Start: End: Hours Unpaid: Amount Claimed: $

4. Pay Period: Start: End: Hours Unpaid: Amount Claimed: $

5. Pay Period: Start: End: Hours Unpaid: Amount Claimed: $

3. CALCULATION OF DAMAGES

Total Regular Wages Claimed: $

Total Overtime Wages Claimed: $

Statutory Penalties and Interest Claimed: $

Other Recoverable Amounts (describe): Amount: $

Total Amount Claimed: $

4. SUPPORTING DOCUMENTS

Check all documents attached or available to support this claim:

Paystubs or wage statements Time sheets / time records

Employment agreement or offer letter Wage notices or pay policies

5. DEMAND FOR RELIEF

Claimant hereby demands payment from Respondent of the Total Amount Claimed above, together with interest, statutory penalties, reimbursement of reasonable costs and attorneys' fees where applicable, and any other relief authorized by law.

6. REPRESENTATIONS AND CERTIFICATIONS

Claimant represents and certifies under penalty of perjury that Claimant is the person who performed the work referenced above, that the amounts set forth are true and accurate to the best of Claimant's knowledge, and that Claimant has not previously been paid the amounts claimed except as noted in this form.

Claimant authorizes the release of payroll and timekeeping records held by Respondent or third parties to the extent necessary to investigate or adjudicate this claim and waives any privacy-based objections to such disclosure for this matter.

7. NOTICES

8. MISCELLANEOUS PROVISIONS

Governing Law: This Claim Form and any dispute arising from it shall be governed by and construed in accordance with the laws of the state in which the work was performed, without regard to conflict-of-law principles.

Entire Agreement: This document constitutes the entire written statement of Claimant's wage-and-hour claim as of the Submission Date and supersedes any prior written statements by Claimant relating to the same incidents or pay periods.

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

Amendments and Waiver: Any amendment to this Claim Form must be in writing and signed by the party to be charged. The failure to enforce any provision shall not be a waiver of the right to enforce that provision later.

Counterparts: This Claim Form may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

9. ACKNOWLEDGMENT

By signing below, each signatory certifies under penalty of perjury that the information contained in this Wage Theft Claim Form is true and correct, and that the signatory is authorized to execute this form on behalf of the party identified.

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