Free 02069 - Indiana

Application For Wage Claim
State Form 2069 (R4 / 2-99) Indiana Department of Labor

Wage Claim #

_________________

Indiana Department of Labor Wage and Hour Division 402 West Washington Street, W195 Indianapolis, IN 46204

(Please type or print your response and be sure to answer all questions) Employee
Name Name

Employer

Address

Address

City State, Zip Telephone

City State, Zip Telephone

Amount of Claim

$

Length of Employment:

From

To

Address Where Work Was Performed: Reason for Leaving Employment: Reason Given For Non-Payment: Wage Agreement: Hourly $ Salary $ Commission $ Piece Rate Payroll Deduction $

Type of Claim: Check box(s)

Minimum Wage Complaint

Non-Payment of Overtime

Non-Payment of Vacation

Non-Payment of Paycheck(s

INSTRUCTIONS:

(1) Show, mathematically, how you calculated the amount of your claim (2) Be sure to list the dates of non-payment, including hours worked each day with beginning and ending times (3) Attach your supporting documentation behind this form

Incomplete Forms
Any incomplete Application For Wage Claim will be returned to its sender in its entirety without any action taken from our Department.

Date Received (Office Use Only)

Disclaimer
The Department of Labor has the right to reject this claim at any time if, in the judgement of the Commissioner of Labor, said claim is not valid and enforceable in the courts.

Declaration
I hereby certify under the penalty of perjury that the above statements are true and that I will testify to same before a court of law, if necessary to collect the amount due to me. Pursuant to IC 22-2-9-5, I hereby assign to the Commissioner of Labor all my rights, title and interest in and to the above certified claim for processing in accordance with the provisions of IC 22-2-9-1, et seq.

Signed

Dated