Form 1 - Initial Report Or Claim - California Labor Commissioner Page 2
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4PRINT YOUR NAME: ________________________________________
Part 4: FIN AL W AG ES / BO U N CED CH ECK S
25. DATE OF HIRE
26. Check which box applies to you:
____/____/_____
___ /___/____
___/___/____
☐
☐
☐
Still working for employer
QUIT on
DISCHARGED on
Month
Day
Year
Month
Day
Year
Month
Day
Year
☐
Other (specify):
_____________________________________________________________________________________
27a
If you QUIT, did you give 72
27b. If you QUIT, have you received your final payment of wages including all wages owed
?
.
hours notice before quitting?
_______ /_______/_________
☐
YES, on:
☐
YES
Month
Day
Year
☐
NO
☐
NO
28. If you were DISCHARGED, have you received your final payment of wages including all wages owed?
☐
_______ /_______/_________
YES, on:
Month
Day
Year
☐
NO
29b.
If paid by check, did any of your paychecks “bounce”
29a. How were your wages paid?
(for example, paycheck could not be cashed because
☐
☐
☐
employer has insufficient funds)?
BY CHECK
BY CASH
BY BOTH CASH & CHECK
☐
☐
☐
OTHER: __________________________________________
YES
NO
Part 5: H O U RS YO U TYPICALLY W O RK ED
☐
30. Check which box applies:
My work hours and days of work were usually the same each week that I worked.
☐
My work hours and/or days of work varied per week or were irregular. If you checked this box
and you are claiming unpaid wages or meal and rest period violations, you should also fill
out and submit the DLSE FORM 55.
31. If your work hours and days of work were usually the same each week, give your BEST ESTIMATE below of the hours you
usually worked and any time you took for a duty-free meal period during your TYPICAL workweek. DO NOT fill this out if
your work hours were too irregular to estimate a typical or average workweek (instead fill out the DLSE Form 55).
TIME WORK
TIME WORK
1st MEAL
1st MEAL
2nd MEAL
2nd MEAL
ONLY IF YOU WORKED A
STARTED
ENDED
START TIME
END TIME
START TIME
END TIME
SPLIT SHIFT:
(if applicable)
(if applicable)
(if applicable)
(if applicable)
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 1
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
workweek:
☐
☐
_______
pm
_______
pm
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 2
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
☐
☐
_______
pm
_______
pm
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 3
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
☐
☐
_______
pm
_______
pm
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 4
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
☐
☐
_______
pm
_______
pm
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 5
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
☐
☐
_______
pm
_______
pm
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 6
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
☐
☐
_______
pm
_______
pm
1st shift ended at
2nd shift started at
☐
☐
☐
☐
☐
☐
DAY 7
am
am
am
am
am
am
☐
☐
am
am
of your
☐
☐
☐
☐
☐
☐
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
☐
☐
:
workweek
_______
pm
_______
pm
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(CONTINUED – Page 2 of 3)
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