Unpaid Wage Claim Form
THE INDUSTRIAL COMMISSION OF ARIZONA
LABOR DEPARTMENT
Unpaid Wage Claim Form
* indicates required field
CLAIMANT INFORMATION :
*
First Name
Error:
Please Enter CLAIMANT First Name.
Middle Name
*
Last Name
Error:
Please Enter CLAIMANT Last Name.
*
Date of Birth
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Please Enter CLAIMANT DOB.
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Address
Error:
Please Enter CLAIMANT Address.
*
City
Error:
Please Enter CLAIMANT City.
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State
--None--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Error:
Please Enter CLAIMANT State.
*
Zip
Error:
Please Enter CLAIMANT Zip.
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Email
Error:
Please Enter CLAIMANT Email.
*
Telephone Number
Error:
Please Enter CLAIMANT Phone.
Cell Phone Number
*
Please indicate your preferred method of communication and service
--None--
E-Mail
Mail
Error:
Please Choose preferred method of communication.
Note: You must promptly notify the Labor Department of any changes to your contact information.
EMPLOYER INFORMATION :
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Employer Business Name
Error:
Please Enter EMPLOYER Name.
*
Address
Error:
Please Enter EMPLOYER Address.
*
City
Error:
Please Enter EMPLOYER City.
*
State
--None--
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Error:
Please Choose EMPLOYER State.
*
Zip
Error:
*
Telephone Number
Error:
Please Enter EMPLOYER Telephone Number.
*
Type of Business
Error:
Please Enter EMPLOYER Type of Business.
Owner’s Name
Owner’s Email
Additional Information (business e-mail address, corporate name, additional business addresses, owner’s cell phone number, etc.):
JOB INFORMATION:
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Your Job Title
Error:
Please Enter Your Job Title.
Work Description
Who hired you:
Their Title/Position:
Who supervised you:
Their Title/Position:
Address where work was done (if different than above):
*
Start Date of Employment:
Error:
Please Start Date of Employment.
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Last Date of Employment: (if not still employed)
Error:
Please Enter EMPLOYMENT End Date or Check Box for Still Employed.
Check box if Still Employed
*
Rate of Pay:
Error:
Please Enter rate of Pay.
*
Per
--None--
Hour
Day
Week
Monthly
Other
Commission
Error:
Please Choose Per.
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How often were you paid:
--None--
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Other
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Was the wage agreement:
--None--
Written
Verbal
Other
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How were you paid:
--None--
Check
Cash
Direct Deposit
Pay Card
Other
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GENERAL JOB INFORMATION QUESTIONS:
Was the job contracted in Arizona?
Yes
No
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Did you quit?
Yes
No
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Were you discharged?
Yes
No
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Do you owe money to the employer?
Yes
No
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Do you have any employer’s property?
Yes
No
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Is the employer still in business?
Yes
No
Has the employer filed for bankruptcy?
Yes
No
Were you an Independent Contractor?
Yes
No
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Did the employer withhold taxes?
Yes
No
Did the employer use time cards?
Yes
No
Error:
You Must Enter at least one Claim Amount
UNPAID WAGE CLAIM DETAILS : FILL OUT ONLY THE SECTION(S) THAT APPLY AND ATTACH SUPPORTING DOCUMENTS. Do NOT deduct taxes from any amounts owed.
HOURLY
# of Hours Unpaid
Hourly Rate
AMT OWED
FROM
TO
SALARY
Select Period
--None--
Hours
Days
Weeks
Months
Quantity
Rate
AMT OWED
FROM
TO
COMMISSION
Gross Sales
Commission % (e.g. 10 for 10%)
AMT OWED
FROM
TO
PIECE RATE
Was Job based on Completion of Work?
Yes
No
AMT OWED
FROM
TO
VACATION/PTO
Select Period
--None--
Hours
Days
Weeks
Months
Rate per Period
AMT OWED
FROM
TO
BONUS - Enter Detail of Bonus Calculation OR please follow directions below to submit an explanation in electronic format (Word, PDF, etc.)
Details
AMT OWED
FROM
TO
UNAUTHORIZED DEDUCTION - Please follow directions below to submit a copy of the paystub(s) showing the deduction(s)
AMT OWED
FROM
TO
MILEAGE
# of Miles
Cents per Mile (enter as decimal)
AMT OWED
FROM
TO
NSF CHECKS - Please follow directions below to submit a copy of bank document(s) or a copy of the NSF check(s)
AMT OWED
FROM
TO
OTHER - Please follow directions below to submit an explanation in electronic format (Word, PDF, etc.)
AMT OWED
FROM
TO
*TOTAL GROSS AMOUNT OWED
Error:
You Must Enter at least one Claim Amount
SUBMITTING AN INCOMPLETE UNPAID WAGE CLAIM FORM MAY DELAY OR RESULT IN DISMISSAL OF YOUR CLAIM.
I hereby certify that this is a true statement to the best of my knowledge and I further certify that the above-listed dates and amounts owed are a complete and accurate accounting. I understand I may have to complete a new Unpaid Wage Claim Form for any additional amounts that I am owed. I understand that acceptance of this Unpaid Wage Claim by the Labor Department does not guarantee an award or collection of an award. I authorize the Labor Department to receive any monies due and to mail such monies to me at my own risk. (Checks may be picked up or will be mailed to the address of file at the Labor Department.)
*
If you have supporting documentation or materials related to this complaint that you would like to upload at this time, please select Yes below. After you click the Submit button below you will be directed to a page where you can upload your files.
Yes
No
Sign and Date Section
*
Your Name
Error:
Please Enter Your Name in Sign and Date Section.
*
Date
Error:
Please Enter Date in Sign and Date Section.