Prevailing Wage Claim Form - Arkansas Department Of Labor
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2ARKANSAS DEPARTMENT OF LABOR
10421 WEST MARKHAM
LITTLE ROCK, ARKANSAS 72205-2190
(501) 682-4536
PREVAILING WAGE CLAIM
CLAIMANT
1.
Name: ______________________________________________________________________________________________
2.
Address: ____________________________________________________________________________________________
(Street & Number)
(City)
(State)
(Zip)
3.
Social Security No. _____________________________________ Telephone No. (______)_______________________
EMPLOYER
4.
Business Name: ______________________________________________________________________________________
5.
Owner: _____________________________________________________________________________________________
6.
Address: ____________________________________________________________________________________________
(Street & Number)
(City)
(State)
(Zip)
7.
Telephone No. __________________________________ Supervisor: ________________________________________
CLAIM
8.
Title of Construction Project: __________________________________________________________________________
9.
Location of Project: __________________________________________________________________________________
(Street)
__________________________________________________________________________________________________
(City and County)
10.
Job Classification: _____________________________________________
Hourly Rate of Pay $ ________________
11.
Hourly Rate Overtime: $ ______________________ Date Hired: _________________ Date Left: _________________
12.
List any fringe benefits paid by employer (including but not limited to insurance, pension, paid vacation or
holidays, training, or other apprenticeship fees): __________________________________________________________
____________________________________________________________________________________________________
13.
Do you have check stubs or other records confirming your rate of pay? _______________________________________
14.
In an average week, how many hours did you work? _______________________________________________________
15.
Briefly explain your duties on the project and the tools you used: ____________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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