Wage Claim Form
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Oklahoma Dept of Labor
Wage Claim Form
Attn: ESD
3017 N Stiles, Suite 100
Oklahoma City, OK 73105
Oklahoma Department of Labor
405-521-6100
888-269-5353
FAX 405-521-6017
Before completing this form PLEASE READ ALL INSTRUCTIONS printed on reverse side
1. YOUR NAME
AGE
GENDER
DATE
Select One
2. HOME TELEPHONE
CELL#
YOUR EMAIL
3. YOUR ADDRESS
CITY
STATE
ZIP CODE
4. CLAIM FILED AGAINST (Name of Business)
OWNER/MANAGER
BUSINESS TELEPHONE
5. BUSINESS ADDRESS
CITY
STATE
ZIP CODE
6. TYPE OF BUSINESS
DESCRIBE WORK PERFORMED
7. BUSINESS FILED BANKRUPTCY?
ARE YOU AN INDEPENDENT CONTRACTOR?
☐ YES
☐ NO
☐ YES
☐ NO
If yes, case number:
8. ADDRESS WHERE WORK WAS PERFORMED:
Street
City
County
9. WERE TAXES DEDUCTED FROM YOUR CHECK?
DATES OF EMPLOYMENT
From (MM/DD/YYYY)
To (MM/DD/YYYY)
☐ YES
☐ NO
10. ARE YOU A MEMBER OF A UNION?
ARE YOU AWARE OF ANY AGREEMENT SUCH AS ARBITRATION?
☐ YES
☐ NO
☐ YES
☐ NO
11. BUSINESS STILL OPEN?
WERE REGULAR WORKING HOURS SET?
☐ YES
☐ NO
☐ YES
☐ NO
12. DID YOU AUTHORIZE DEDUCTIONS OTHER THAN REGULAR PAYROLL TAX, ETC?
☐ YES
☐ NO
If yes, what deductions?
13. DID YOU RECEIVE A PAY STUB FROM YOUR EMPLOYER OUTLINING AND/OR SHOWING ALL DEDUCTIONS FROM YOUR PAYCHECK? (TAXES,
☐ YES
☐ NO
INSURANCE, ETC.)
14. WHO HIRED YOU?
WAS EMPLOYMENT AGREEMENT:
☐ ORAL
☐ WRITTEN
If written, attach copy to claim form.
15. DO YOU HAVE ANY OF THE EMPLOYER’S PROPERTY?
HAVE YOU ASKED FOR YOUR WAGES?
☐ YES
☐ NO
☐ YES
☐ NO
16. WERE YOU PAID WITH ANY INSUFFICIENT CHECK(S)?
IF YES, IS THE AMOUNT INCLUDED IN TOTAL AMOUNT OF CLAIM?
☐ YES
☐ NO
☐ YES
☐ NO
17. SALARY OR HOURLY RATE OF PAY
REGULARLY SCHEDULED PAYDAYS
(Examples: $7.25 per hour, 20% commission)
Weekly Bi-Weekly Monthly Bi-Monthly Other (specify):
18. ARE YOU RELATED TO YOUR EMPLOYER?
IF YES, WHAT IS YOUR RELATIONSHIP?
☐ YES
☐ NO
19. REASON GIVEN BY EMPLOYER FOR NON-PAYMENT OF WAGES
DO YOU OWE MONEY TO THE EMPLOYER?
☐ YES
☐ NO
20. HAVE YOU RETAINED AN ATTORNEY?
☐ YES
☐ NO
If yes, name, address, and telephone of attorney:
21. HAVE YOU FILED IN CIVIL COURT?
☐ YES
☐ NO
If yes, case number:
22. GROSS DOLLAR AMOUNT OF YOUR CLAIM (BEFORE TAXES):
USE THIS SPACE TO EXPLAIN CLAIM INCLUDING DATES AND AMOUNTS:
(If more than one type of wage is due, fill in each amount AND attach documents)
DATE(S) WAGES WERE DUE (MM/DD/YYYY): __________________________
a.
$_____________________REGULAR
_________________________________________________________________
b.
$_____________________COMMISSION
_________________________________________________________________
c.
$_____________________MINIMUM WAGE
_________________________________________________________________
d.
$_____________________BENEFITS
_________________________________________________________________
e.
$_____________________DEDUCTIONS
_________________________________________________________________
f.
$_____________________OVERTIME
_________________________________________________________________
g.
$_____________________MISC.
$_____________________TOTAL AMOUNT CLAIMED
FOR OFFICE USE ONLY
Walk In: ☐ Yes ☐ No
FILE DATE: _________________ FILE NO: ________________________________
ID: ______
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Parent category: Legal