Labor Commission Wage Claim Intake Form

Employee Name*

Name of employee who submitted the wage claim

Employee ID

Provide Employee ID, if known. This is helpful for identifying the employee, particularly in cases where there are multiple people with the same name.

Department*

Wage Claim #*

The wage claim # provided by the Labor Commissioner's Office, if given.

Date Wage Claim was Filed with Labor Commissioner*

Date You Received the Wage Claim*

Your Name*

Your Email*

Your Phone Number*

Issue Description*

Provide a short description of the wage claim you received.

Scanned Wage Claim Attachments*

Scan the wage claim you received and attach it to your submission.

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