Wage Claim Assignment Form printable pdf download

Wage Claim Assignment Form

Page 1 of 4

Utah Labor Commission

Wage Claim Unit

160 East 300 South, 3

Floor

PO Box 146630

Salt Lake City, UT 84114‐6630

Wage Claim No:

Phone: 801‐530‐6801

Fax: 801‐530‐7609

________________

Email: wcu@utah.gov

Amount $___________

Wage Claim Assignment Form

(For Office Use Only)

(Do Not Mark in this Space)

07-14

Jurisdiction:

The Wage Claim Unit can only accept claims for wages earned within the last year from the date the wage claim is filed.

Claims must also be for at least $50 but no more than $10,000. Also, we do not have jurisdiction over public employees.

PRINT CLEARLY ALL INFORMATION. YOU MUST COMPLETE ALL 4 PAGES.

Your Name:

Date of Birth:

Mailing Address:

Email Address:

Apt #

City: State: Zip:

Telephone #

Cell #

Name, address & telephone number of nearest relative or contact person not living with you (as a way to locate you if

the Division cannot contact you):

Name of Your Employer’s Business:

Telephone #

Type of Business:

Address:

Website (If known):

Owner’s Name (If known):

Suite #

City: State: Zip:

Owner’s Home Address (If known):

Additional Information: (ex: corporate name, additional addresses, phone numbers, etc.)

Your Job Title

Construction

Retail

Call Center

Restaurant/Hotel

Janitorial

Trucking

Other

Type of Work Performed:

Who Hired You?

Their Position/Title:

Who Supervised You?

Their Position/Title:

Address Where Work Was Done?

Start Date Of Employment? (mm/dd/yyyy)

Last Date Of Employment: (mm/dd/yyyy)

Your Rate of Pay:

$  Hour  Day  Week  Monthly  Other (Explain):

Wage Claim Assignment Form

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