Unpaid Wage Claim Form
THE INDUSTRIAL COMMISSION OF ARIZONA
LABOR DEPARTMENT
Unpaid 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 :

JOB INFORMATION:

GENERAL JOB INFORMATION QUESTIONS:

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
SALARY
COMMISSION
PIECE RATE
VACATION/PTO
BONUS - Enter Detail of Bonus Calculation OR please follow directions below to submit an explanation in electronic format (Word, PDF, etc.)
UNAUTHORIZED DEDUCTION - Please follow directions below to submit a copy of the paystub(s) showing the deduction(s)
MILEAGE
NSF CHECKS - Please follow directions below to submit a copy of bank document(s) or a copy of the NSF check(s)
OTHER - Please follow directions below to submit an explanation in electronic format (Word, PDF, etc.)
*TOTAL GROSS AMOUNT OWED
 
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.)

 

Sign and Date Section