Free La Comision Industrial De Arizona Reclamacion D - Arizona

The Industrial Commission of Arizona State Labor Department P.O. Box 19070 Phoenix, Arizona 85005-9070 Phone (602) 542-4515 A copy of this claim will be sent to the employer PLEASE PRINT WITH A BLACK PEN. CLAIMANT'S INFORMATION:
Your Name:

WAGE CLAIM

(Pursuant to A.R.S. §23-356)

FOR OFFICE USE ONLY WAGE CLAIM NO.

INFORMATION ABOUT EMPLOYER:

Name of Business: Apt #

Address:
City/State:

Address: City/State:
Owner's Name: Vehicle License No: Corporation Name: Type of Business: Telephone No.:

Suite Zip

Zip (Please notify Dept. of address changes)

(Provide additional addresses on separate sheet of paper)

Date of Birth: *Social Security No.: Telephone No. Home: Message Telephone No:

Corporation No:

1. Who hired you? 2. Under whom did you work? 3. What type of work did you perform? 4. Address where work was done?

Title: Title: Your Job Title:

5. Start date of employment? 6. Last day worked? 7. What was your rate of pay did you and your employer agree to Hourly: $___________ Weekly: $____________ Monthly: $_____________ Other (explain)$_____________________________ 8. Was this agreement:
Written _________ Weekly ________ Verbal: _________ Bi-Weekly _________ Monthly _________

9. How often were you paid?
Or Other (explain)

10. What were the dates of your regular scheduled paydays? 11. How were you paid? Check ! Cash ! 12. Are you still working for this employer? 13. Did you quit? Yes ! No ! Other ! Yes ! Explain: No ! Why? Explain: Yes ! No !

Were you discharged? Yes ! No !

14. Is the employer still in business? Yes ! No ! What is the owner's home address? 15. Did your employer deduct social security and withholding of taxes? Did you sign a W-4 form? Yes ! No !

Has your employer filed "Bankruptcy"?

Telephone #: Yes ! No !

_________________

Are you an independent contractor? Yes ! No! !

16. Did you sign an authorization for other deductions? Yes ! No ! If yes, explain: 17. Did your employer set regular working hours? Yes ! No !. Did they keep timecards? Yes ! No ! 18. Did you obtain this job through a private employment agency or State Agency? Yes ! No ! If so, indicate: Name of Agency: Telephone No: Address: Contact Person: 19. Did you sign any contract or agreement with this employer? Yes ! No ! Is yes, submit copy & explain: *Disclosing your social security number is voluntary. It will assist in the processing of your case. 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.

$
20. What is the (gross) amount of your claim? FOR: 21. ! Unpaid Wages (complete line #22) ! Unauthorized Deductions (complete line #24) (Submit copy of pay-stub showing deductions) 22. Dates for which wages were not paid _____________________________ to ________________________________ (M/D/Y) (M/D/Y) Hours worked (not paid): ______________________ At rate of pay per hour:_____________________ = $ ____________________ (Submit any records kept or a complete list of dates and hours worked) (Do not include any overtime you may contact Federal Wage & Hour Division regarding overtime laws.) If "Salary" week(s) not paid___________ at $____________ =$ _______________ Weekly/Bi-weekly/Semi-Monthly (circle one) 23. If Commissions, Percentage you were to receive? ________%. Total sales (gross amt) $ _____________ =$___________________ (do not include taxes & social security) to arrive at total amt claiming ) Submit a complete breakdown and/or an itemization of such sales, etc on a separate sheet of paper) What was the employer's agreement for time of payment? Explain fully:_________________________________________________ ____________________________________________________________________________________________________________ {Submit a complete list of commissions earned} Example: 15% of 2500.00 = $ 375.00 to arrive at total gross amt. 24. If deductions: Why were deductions made?____________________________________________ Amt $____________________ Pay period in which deductions were made:________________________________________________________________________ Did you sign anything authorizing such deductions? Yes ! No ! If yes, submit copy of pay-stub showing deductions. Does company policy state that employees are responsible for such deductions? Yes ! No ! 25. If Vacation: How did you arrive at the amount of your claim in No.#20 above? ___________________________________________ (submit copy of policy or explain fully what was promised and by whom: _______________________________________________ Date(s) work was performed to earn benefits or wages:_______________________________________________________________ If Other: How did you arrive at the amount of your claim in No.#20 above.?_____________________________________________ If company benefit, (submit copy or explain fully):__________________________________________________________________ Date(s) work was performed to earn benefits or wages:_______________________________________________________________ {Additional information for any of the above areas can be itemized on a separate sheet of paper} 26. Do you owe any money to the employer? Yes ! No ! If yes, how much? $ ____________ (explain): 27. Do you have any of the employer's property? Yes ! No ! If yes, explain what property Value of property $____________ (All property, keys, etc. must be returned to the employer before filing a wage claim) 28. Did you ask for your wages? Yes ! No ! If yes, on what date(s): Reason given by the employer for non-payment of wages: ! Commission (complete line #23)

! Vacation Pay (complete line #25) ! Other (use line #25) ! Insufficient funds, submit original check (use line #25)

Check this form over carefully to be sure you have answered the questions completely, otherwise, it may be returned for further information and delay processing. I HEREBY CERTIFY that this is a true statement to the best of my knowledge and belief. I UNDERSTAND that acceptance of this claim by the Labor Department does not guarantee collection. I AUTHORIZE the Department to receive any monies due to me and to mail such monies at my own risk. _______________________________________ _____________________________________________________ Date Signature I HEREBY ATTEST that I have reviewed this claim and have determined that it contains sufficient information for acceptance by the Labor Department pursuant to A.R.S. 23-356. _______________________________________ ___________________________________________________ Date Examiner Tech Signature

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Intake: Office ! Mail !