Wage Complaint Form
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1
2
3S.C.
S.C.
S.C.
S.C.
S.C. DEP
DEP
DEP
DEPAR
DEP
AR
AR
AR
ARTMENT OF LABOR,
TMENT OF LABOR,
TMENT OF LABOR,
TMENT OF LABOR,
TMENT OF LABOR, LICENSING AND REGULA
LICENSING AND REGULA
LICENSING AND REGULA
LICENSING AND REGULATION
LICENSING AND REGULA
TION
TION
TION
TION
DIVISION OF INVESTIGA
DIVISION OF INVESTIGA
DIVISION OF INVESTIGA
DIVISION OF INVESTIGA
DIVISION OF INVESTIGATIONS AND ENFORCEMENT/OFFICE OF
TIONS AND ENFORCEMENT/OFFICE OF
TIONS AND ENFORCEMENT/OFFICE OF
TIONS AND ENFORCEMENT/OFFICE OF
TIONS AND ENFORCEMENT/OFFICE OF W W W W W A A A A A GES AND CHILD LABOR
GES AND CHILD LABOR
GES AND CHILD LABOR
GES AND CHILD LABOR
GES AND CHILD LABOR
Date: _____/_____/_____
Case Number: ____________________
Mo
Day
Yr
CLAIMANT INFORMA
CLAIMANT INFORMA
CLAIMANT INFORMATION
CLAIMANT INFORMA
CLAIMANT INFORMA
TION
TION
TION
TION
Name _________________________________________
Phone (_______)______________________________
Last
First
Middle Initial
Area Code
Address _______________________________________
SSN _________________________________________
Street Address or Box Number
City _____________________ County ______________
Date of: Employment _____/_____/_____
Mo
Day
Yr
State ____________________ Zip _________________
Separation _____/_____/_____
Mo
Day
Yr
Discharged ____ Quit ____ Still Working ____
EMPLO
EMPLO
YER INFORMA
YER INFORMA
TION
TION
EMPLO
EMPLOYER INFORMA
EMPLO
YER INFORMA
YER INFORMATION
TION
TION
Company ______________________________________
Phone (_______)______________________________
Area Code
Contact Person _________________________________
Title _________________________________________
Address _______________________________________
Type of Business ______________________________
Street Address or Box Number
City _____________________ County ______________
Number of Employees ___________________________
State ____________________ Zip _________________
ADDITIONAL INFORMA
ADDITIONAL INFORMA
ADDITIONAL INFORMA
ADDITIONAL INFORMA
ADDITIONAL INFORMATION
TION
TION
TION
TION
CLAIM INFORMA
CLAIM INFORMA
CLAIM INFORMA
CLAIM INFORMA
CLAIM INFORMATION
TION
TION
TION
TION
BASIS OF CLAIM
BASIS OF CLAIM
BASIS OF CLAIM
BASIS OF CLAIM
BASIS OF CLAIM
Employee Occupation ____________________________
Wages ______ Vacation _______ Commission _______
Rate of Pay: $_____________ per ___
Bad Check _______ Other _______
Other: _____________________________
UNP
UNP
UNP
UNP
UNPAID
AID
AID
AID
AID TIME
TIME
TIME
TIME
TIME W W W W W ORKED
ORKED
ORKED
ORKED: Hours __________________
ORKED
Deductions: Yes _____ No _____
Dates ________________________________________
Fed. _____ State _____ FICA _____ Other __________
AD
AD
AD
AD
ADV V V V V ANCE/Setoff
ANCE/Setoff
ANCE/Setoff
ANCE/Setoff
ANCE/Setoff: Yes ____ No ____ Amt $ ________
P P P P P A A A A A Y PERIOD
Y PERIOD
Y PERIOD
Y PERIOD
Y PERIOD
Net amount owed by employer: ___________________
Weekly ______________ Bi-weekly _________________
CLAIMANT REQ
CLAIMANT REQ
CLAIMANT REQ
CLAIMANT REQ
CLAIMANT REQUESTED
UESTED
UESTED
UESTED W W W W W A A A A A GES
UESTED
GES
GES
GES
GES: Yes ____ No ____
Monthly ______________ By the job or other __________
Date: _________________________
SPECIFIC PAYDAY: ______________________________
From Whom: __________________________________
SPECIFIC PAY DATE: ____________________________
CLAIMANT RECEIVED
CLAIMANT RECEIVED
CLAIMANT RECEIVED
CLAIMANT RECEIVED
CLAIMANT RECEIVED WRITTEN NO
WRITTEN NO
WRITTEN NO
WRITTEN NO
WRITTEN NOTIFICA
TIFICA
TIFICA
TIFICA
TIFICATION AS
TION AS
TION AS
TION AS
TION AS
Time & Place of Payment: _________________________
REQUIRED BY 41-10-30 (A)
REQUIRED BY 41-10-30 (A)
REQUIRED BY 41-10-30 (A)
Y Y Y Y Y es _____ No _____
es _____ No _____
es _____ No _____
es _____ No _____
REQUIRED BY 41-10-30 (A)
REQUIRED BY 41-10-30 (A)
es _____ No _____
Where work performed: ___________________________
____________________________________________
Investigator ____________________________________
Claimant’s Signature
Date
WCL-3 (Rev. 9/05)
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