Form Wh-9 - Employment Information Form Page 2

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Page 2
Wage Claim Form
Method of payment:
$_______________
per______________________
(rate)
(hour, week, month, etc.)
Enter in the boxes below the hours you usually work each day and each week
(less time off for meals):
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total
CHECK THE APPROPRIATE BOX(ES):
Does not pay the minimum wage
Does not pay proper overtime
Deductions from wages
Failure to pay wages
EXPLAIN BRIEFLY IN THE SPACE BELOW the employment practices which you believe violate the
Wage and Hour Laws.(If you need more space use an additional sheet of paper and attach it to this form.)
(NOTE:
)
If you think it would be difficult for us to locate the establishment or where you live, give directions or attach a map
I hereby affirm that the above charge is true to the best of my knowledge, information and belief.
_________________________________________________
__________________________
Signature of Complainant
Date

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Parent category: Legal
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