Form Sfn 17081 - Claim For Wages Page 2
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5SFN 17081 (8-2017)
Page 2 of 5
DATA COLLECTION
No
Are you claiming wages for work performed in North Dakota?
Yes
Are you authorized to legally work in the United States?
Yes
No
Yes
No
Do you have a child support judgment against you in North Dakota?
Yes
No
Was the work you are claiming payment for, performed for a tribal entity?
Yes
No
Did your employer withhold taxes?
Yes
No
Did your employer keep time cards?
Yes
No
Do you owe your employer money?
If Yes, Describe
Yes
No
Do you currently possess any of your employer's property?
If Yes, Describe
Yes
No
Yes
No
Were you paid in cash?
If yes, did you sign receipts?
Have you made a request to your employer for the wages you believe are owed?
Yes
No
If yes, ATTACH.
ABOUT YOU
Name (First, Last)
Mailing Address
City
State
ZIP Code
Email Address
Yes
No
DO YOU CONSENT TO RECEIVING CORRESPONDENCE EXCLUSIVELY AT THIS EMAIL ADDRESS?
Telephone Number
Alternate Telephone Number
Job Title
Time Period for Which You Are Claiming Wages (Mo/Da/Yr - Mo/Da/Yr)
Date of Hire (MM/DD/YYYY)
Last Day of Employment (MM/DD/YYYY)
Briefly Describe Your Job
Are you still employed?
If not employed, specify reason
Yes
No
Discharged
Laid Off
Quit
Other (specify):
Are you represented by an attorney specific to this matter?
Yes
No
If yes, provide attorney contact information here. Once represented we are required to work through your attorney.
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Parent category: Legal