Form 1 - Initial Report Or Claim - California Labor Commissioner Page 3
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4Part 6: PAYM EN T O F W AG ES
32. Were you paid or promised a FIXED amount of wages per pay period, no matter how many hours you worked (for
example, $400 per week, regardless of how many hours you worked)?
☐
☐
☐
☐
☐
☐
$
YES
I was paid
per
:
day
week
every 2 weeks
month
semi-monthly
___________________
☐
other (specify):__________________________________________________
☐
☐
☐
☐
☐
$
I was promised
_____________ per
day
week
every 2 weeks
month
semi-monthly
☐
other (specify):__________________________________________________
☐
NO
33b.
If you were an HOURLY employee, were you paid or promised more
than one hourly rate (based on the hours you worked or different job
33a. Were you an HOURLY employee?
tasks)?
☐
$
YES
I was paid
per hour.
☐
:
______________
YES (describe):
$
I was promised
_____________ per hour.
☐
NO
☐
NO
☐
☐
☐
☐
34. Were you paid by PIECE RATE?
YES
NO
35. Were you paid by COMMISSION?
YES
NO
Part 7: W AG ES, CO M PEN SATIO N & PEN ALTIES O W ED
36. CLAIMS
CLAIM PERIOD:
CLAIM PERIOD:
AMOUNT EARNED / CLAIMED
(Check all boxes below that apply)
START DATE
END DATE
(Month/ Day/ Year)
(Month/ Day/ Year)
☐
REGULAR WAGES (for non-overtime hours)
$
☐
OVERTIME WAGES (including double time)
$
☐
MEAL PERIOD WAGES
$
☐
REST PERIOD WAGES
$
☐
SPLIT SHIFT PREMIUM
$
☐
REPORTING TIME PAY
$
☐
COMMISSIONS ***
$
☐
VACATION WAGES ***
$
☐
BUSINESS EXPENSES
$
☐
UNLAWFUL DEDUCTIONS
$
☐
OTHER (Specify):
$
ENTER SUBTOTAL (add all Amounts Earned/Claimed):
$
ENTER TOTAL AMOUNT PAID:
$
$
GRAND TOTAL OWED [
]:
Subtotal minus Total Amount Paid
***
Additional DLSE form should be submitted if you are making this claim. See “Instructions for Filing a Wage Claim.”
☐
37.
Check box(es) if you are claiming:
Waiting time penalties [Labor Code §203]
☐
Penalties for “bounced” checks (checks issued with insufficient funds) [Labor Code §203.1]
I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection. The amounts claimed are based on my
best estimates at this time and may be adjusted based on further information, or based on assistance with my claim provided by DLSE.
Signed: __________________________________________________
Date: ________________________________________________
Print Name: ______________________________________________
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(CONTINUED – Page 3 of 3)
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