Wage Claim Form
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1
2Wage Claim Form
Tulsa
Oklahoma City
440 South Houston, Suite 300
3017 N. Stiles, Suite 100
Oklahoma Department of Labor
Oklahoma City, OK 73105
Tulsa, OK 74127
405-521-6100
918-581-2400
888-269-5353
ok.gov/odol
This form cannot be accepted by fax or email.
read all instructions
Before completing this form,
printed on the reverse side of this form.
AGE
DATE
GENDER
1. YOUR NAME
_______________________________________________________________________________________________________________________________________________________
Your Email
2. HOME TELEPHONE
CELL #
_______________________________________________________________________________________________________________________________________________________
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? Yes (
) No (
)
IF YES, CASE NUMBER:
_______________________________________________________________________________________________________________________________________________________
8. ADDRESS WHERE WORK WAS PERFORMED:
Street
City
County
_______________________________________________________________________________________________________________________________________________________
9. WERE TAXES DEDUCTED FROM YOUR CHECK? Yes (
) No (
)
DATES OF EMPLOYMENT? (MM/DD/YYYY)
From:
To:
_______________________________________________________________________________________________________________________________________________________
10. DID YOU RECEIVE A CHECK STUB WITH YOUR PAYCHECK? Yes (
) No (
)
ARE YOU AN INDEPENDENT CONTRACTOR? Yes (
) No (
)
_______________________________________________________________________________________________________________________________________________________
11. BUSINESS STILL OPEN? Yes (
) No (
)
WERE REGULAR WORKING HOURS SET? Yes (
) No (
)
_______________________________________________________________________________________________________________________________________________________
12. DID YOU AUTHORIZE DEDUCTIONS OTHER THAN REGULAR PAYROLL TAX, ETC.?
_______________________________________________________________________________________________________________________________________________________
13. WHO HIRED YOU?
WAS AGREEMENT:
Oral (
) Written (
) If written, attach copy to claim form.
_______________________________________________________________________________________________________________________________________________________
14. DO YOU HAVE ANY OF THE EMPLOYER'S PROPERTY?
Yes (
) No (
)
Yes (
) No (
)
HAVE YOU ASKED FOR YOUR WAGES?
_______________________________________________________________________________________________________________________________________________________
15. WERE YOU PAID WITH ANY INSUFFICIENT CHECK(S)?
Yes (
) No (
)
IF YES, IS AMOUNT INCLUDED IN TOTAL AMOUNT OF CLAIMED?
Yes (
) No (
)
____________________________________________________________________________________________________________________________________________________
16. SALARY OR HOURLY RATE OF PAY
REGULARLY SCHEDULED PAYDAYS
(Examples: $5 per hour, 20% commission)
Bi-Monthly
Other (specify):
Weekly
Bi-Weekly
Monthly
____________________________________________________________________________________________________________________________________________________
17. ARE YOU RELATED TO YOUR EMPLOYERS?
Yes (
) No (
)
IF YES, WHAT IS YOUR RELATIONSHIP?
____________________________________________________________________________________________________________________________________________________
18. REASON GIVEN BY EMPLOYER FOR NON-PAYMENT OF WAGES
DO YOU OWE MONEY TO THE EMPLOYER?
Yes (
) No (
)
____________________________________________________________________________________________________________________________________________________
19. HAVE YOU RETAINED AN ATTORNEY?
Yes (
) No (
)
IF YES, name, address and telephone of attorney:
____________________________________________________________________________________________________________________________________________________
20. HAVE YOU FILED IN CIVIL COURT?
Yes (
) No (
)
IF YES, case number:
____________________________________________________________________________________________________________________________________________________
21.
):
(If more than one type of wage is due, fill in each amouna AND attach documents.)
GROSS AMOUNT OF YOUR CLAIM (before taxes
a. $_____________ Regular
USE THIS SPACE TO EXPLAIN CLAIM INCLUDING DATES:
b. $_____________ Commission
Date wages were due (MM/DD/YYYY): _______________________
c. $_____________ Minimum Wage
d. $_____________ Benefit
e. $_____________ Deduction
f. $_____________ Overtime
g. $_____________ Miscellaneous
$____________ TOTAL AMOUNT CLAIMED
WCF 2011-01
FOR OFFICE USE ONLY
Walk In:
Yes (
) No (
)
FILE DATE:_____________________
FILE NO: ___________________ ID: ___________________________
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