Minimum Wage Claim Form
THE INDUSTRIAL COMMISSION OF ARIZONA
LABOR DEPARTMENT
Minimum Wage Claim Form
* indicates required field

CLAIMANT INFORMATION:
Note: You must promptly notify the Labor Department of any changes to your contact information.

EMPLOYER INFORMATION:

EMPLOYMENT INFORMATION:

COMPLAINT INFORMATION:
Note: If you wish to pursue a minimum wage retaliation claim, you must also complete the Retaliation Complaint Form.

Minimum Wage Claim Form
Indicate, by pay period, all hours worked and when minimum wage was not received.
#
From Date
To Date
HOURS WORKED
RATE OF PAY
TIPS RECEIVED
GROSS EARNED
SHORTED WAGE
1
2
3
4
5
6
7
8
9
10


 

Sign and Date Section
7/8/2020 ]





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