Form 1 - Initial Report Or Claim - California Labor Commissioner
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LABOR COMMISSIONER, STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT
Initial Report or Claim
FOR OFFICE USE ONLY
Taken by:
Taken by: Office:
Case #:
PLEASE PRINT OR TYPE ALL INFORMATION
Taken by:
Date filed:
SIC #:
Refer to the accompanying Guide to assist you in filling out this form.
RCI Complaint:
Action:
☐
☐
YES
NO
PRELIM IN ARY Q U ESTIO N S
1.
Is your claim about a public works project?
[If your answer is “YES,” STOP here, DO NOT FILL OUT THIS FORM, and fill out the “PW-1” claim
form instead. If your answer is “NO,” proceed with this form.]
2.
Have you filed a retaliation complaint against your employer with the Labor Commissioner?
☐
☐
YES, on: _________/________/________
NO [ If you have been retaliated against, you may file a retaliation
Month
Day
Year
complaint by filling out another form, “DLSE FORM 205.”]
3.
Is there a union contract covering your employment?
☐
YES
[If “YES,” attach a copy of the Collective Bargaining Agreement.]
☐
NO
☐
☐
☐
4.
Are other employees also filing wage claims against your employer?
YES
NO
I DON’T KNOW
Part 1: LAN G U AG E ASSISTAN CE & REPRESEN TATIO N
5a
5b
. Do you need an interpreter?
. If you checked “YES” to Box 5a, enter the language needed
☐
☐
YES
NO
6a
6b
. If you are being assisted with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME
. ADVOCATE’S PHONE
and ORGANIZATION
(
)
6c
CITY
STATE
ZIP CODE
. Your ADVOCATE’S MAILING ADDRESS
(Number, Street, Floor, Suite)
Part 2: YO U R IN FO RM ATIO N
7
8
9
10
11
. Your FIRST NAME
. Your LAST NAME
. HOME PHONE
. OTHER PHONE
. BIRTH DATE
(
)
(
)
12
CITY
STATE
ZIP CODE
. Your MAILING ADDRESS
(Street Number, Street Name, Apartment Number)
Part 3: CLAIM FILED AG AIN ST (EM PLO YER IN FO RM ATIO N )
13
14
15
. EMPLOYER / BUSINESS NAME(S)
.
. EMPLOYER
PHONE
EMPLOYER’S VEHICLE LICENSE PLATE #
(
)
16
CITY
STATE
ZIP CODE
. ADDRESS of EMPLOYER / BUSINESS
(Street Number, Street Name, Floor, Suite):
17
CITY
STATE
ZIP CODE
. ADDRESS where you worked, if different from Box 16
(Number, Street, Floor, Suite):
18
19
. NAME of PERSON IN CHARGE
. JOB TITLE / POSITION of PERSON IN CHARGE
(First Name, Last Name)
20
21
22
23
.
.
.
.
TYPE OF BUSINESS
TYPE OF WORK PERFORMED
TOTAL NUMBER
EMPLOYER STILL IN BUSINESS?
OF EMPLOYEES
☐
☐
☐
YES
NO
DON’T KNOW
24
. Check which box describes your employer, if you know: ☐CORPORATION
☐INDIVIDUAL
☐
PARTNERSHIP
☐
LLC
☐
LLP
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(Page 1 of 3)
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