Form Sfn 17081 - Claim For Wages

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CLAIM FOR WAGES
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
SFN 17081 (8-2017)
Instructions
The North Dakota Department of Labor and Human Rights ("Department") enforces wage and hour laws and resolves wage
disputes between employees and employers, with the authority to collect non-payment or improper payment of wages (for
example, non-payment of wages earned, unauthorized paycheck deductions, failure to pay overtime, minimum wage, or
paid time off). Filing with the Department should be your last resort - your claim may not be accepted unless you have made
a demand for your wages. Some situations prevent us from pursuing wage claims until or unless certain events have
occurred. Your claim will not be accepted if you do not provide the information requested below. Once your claim is
accepted, your cooperation is required. Your failure to cooperate with the investigation may result in the dismissal of your
claim. The provision of false information in this claim is a crime under N.D.C.C. 34-14-07. You must use a blue or
black pen.
I CERTIFY I HAVE READ THESE INSTRUCTIONS AND UNDERSTAND MY RIGHTS AND DUTIES
Signature
Date
In order to file a claim, you must acknowledge the following (INITIAL EACH ITEM):
I am the claimant and I carry the initial burden of proof.
I understand that information I submit may be shared with my employer.
I understand that the information I submit must be complete and I must provide sufficient information for the
Department to pursue my claim, and that my failure to provide the requested information may result in the rejection
of my claims.
I agree to provide the Department with contact information where I can be reached, to cooperate fully with any
investigation, to promptly respond to the Department inquiries and requests, and to provide new contact information
within three (3) days of any change.
I agree to notify the Department of any payment made directly to me by my employer within three (3) days of receipt.
I understand that I am providing information to the Department to determine the merit of my claim and the act of
submitting this information does not guarantee that a claim will be opened, or if it is, that wages will be recovered.
I agree to assign all wages and penalties accruing because of their non-payment, if any, and all liens or actions
securing them to the Commissioner of Labor. I authorize the Commissioner of Labor to approve a proposed
compromise adjustment or settlement of this claim.
ELIGIBILITY
Your claim cannot be pursued if:
The claim is less than $125. You may be able to pursue your claim in small claims court.
The claim more than $15,000. You may be able to pursue your claim in District Court.
You are an independent contractor
You are an owner or partner in the business.
You have begun private legal action in court.

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