Claimant Information Your Name DOB City State Zip Email Phone Employer Information Business Name Phone Type of Business Address City State Zip Owner222s Name Owner222s Address (if available) Additional Information (Corporate Name, Mailing Address, addl. phone numbers) Job Information Type of work performed: Their title/ position: Their title/position: Last date of employment: Per: Hour Day Week Month Year Other Weekly Bi-Weekly Semi-Monthly Bi-Monthly Other? Written Verbal (if written provide copy) Your job title: Who hired you? Who supervised you? Address where work was done: Start date of employment: Rate of pay How often were you paid? Was wage agreement? How were you paid? Check Cash Direct Deposit Pay Card Other? General Job Information Questions Was the job contracted in Arizona? Yes No Did you quit? Yes No Were you discharged? Yes No Do you owe money to the employer? Yes No Explain: Do you have employer222s property? Yes No Did you ask for your wages? Yes No If no, where? If yes, why? If yes, why? If yes, $ If yes, what? If yes, enter date(s). Reason given for non-payment of wages: Is the employer still in business? Yes No Did the employer file bankruptcy? Yes No Were you an Independent Contractor? Yes No Did your employer withhold taxes? Yes No Did the employer keep time cards? Yes No Continue on 2nd page *Disclosing your social security number is voluntary. It will assist in processing your claim. It will also be used by this agency in carrying out its other duties including, but not limited to; proper identification, law enforcement, claim processing and program administration. Name American LegalNet, Inc. www.FormsWorkFlow.com Wage Claim Page 2 Complete the sections that apply to your wage claim. Attach supporting documents. Hourly Effective Dates, use 223mm/dd/yy224 format No. of hours unpaid X $ (rate of pay) = $ From To Salary From To HoursDaysWeeks Total of: X $ (rate of pay) = $ Commission Explain commission agreement (Submit on separate sheet of paper) Total sales amount $ X % = $ From To Piece Rate Was job based on completion of work?YesNo Enter Amount Owed $ From To Vacation/PTO/Sick Time Submit copy of policy From To Total of X $ (rate of pay) = $ Bonus Explain bonus agreement (Submit on separate sheet of paper) Enter amount of bonus owed. $ From To Unauthorized Deductions Submit copy of paystub(s) Enter amount $ From To Mileage (Number of miles) X Cents per mile. = $ From To NSF Check(s) Submit bank documents Enter amount $ From To Other (Attach an explanation on a separate sheet of paper) Enter amount $ From To Enter Total Gross Amount $ (Do not deduct any taxes) IF YOUR WAGE CLAIM IS INCOMPLETE IT MAY BE RETURNED TO YOU; AN INCOMPLETE WAGE CLAIM MAY DELAY THE PROCESS OR EVEN CAUSE A DISMISSAL OF YOUR WAGE CLAIM. I hereby certify that this is a true and accurate statement to the best of my knowledge. I understand that acceptance of this claim by the Labor Department does not guarantee collections. I authorize the Labor Department to receive any monies due to me and to mail such monies at my own risk. (Checks will be mailed certified to your address listed with the Labor Department.) Date Claimant222s Signature Date Office intake CSR Signature American LegalNet, Inc. www.FormsWorkFlow.com STATE LABOR DEPARTMENT P.O. Box 19070 Phoenix AZ 85005 -9070 Print Your Name: 1. READ THOROUGHLY & INITIAL: The amount owed cannot exceed $5,000.00. Wages may be filed as long as it is within one (1) year from the accrual of wages. We are not able to accept any request for confidentiality. Return any employer222s property, before filing a claim, value of property may be deducted. The form needs to be readable, or it will be returned. Any additional wages owed after the filing of a claim, the Dept. will close current claim and have you refile. The Department strives to resolve the unpaid wage claim within 90 days. 2.FILLED OUT THE ATTACHED WAGE CLAIM FORM 3. INDICATE TYPE OF WAGES: HOURLY, SALARY, VACATION, MILEAGE, COMMISSION, NSF, OTHER , VERIFY THAT THE INFORMATION BELOW WAS PROVIDED, BY INDICATING YES OR NO. 1 Your complete Name & physical or mailing address, phone, cell #, e-mail entered? YESNO 2. Name of Business or Responsible party, physical or mailing address, phone #, email entered? YESNO 3. Start & Last date of employment entered? YESNO 4. A copy of the agreement attached? (or explain on separate sheet of paper) YESNO 5. Dates are entered with Month/Day/Year? YESNO 6. Copy of paystub, and timecards submitted? YESNO 7. Co Policy, paystub, Stop payment or NSF check, Commission/Mileage Breakdown, Attached? YESNO 8. Did you print & sign your name with current date? YESNO A COPY OF A PHOTO ID IS REQUIRED, ALONG WITH ANY PROOF OF EMPLOYMENT Was this checklist helpful? Yes No If no, please comment: American LegalNet, Inc. www.FormsWorkFlow.com