Form Sfn 17081 - Claim For Wages Page 3
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5SFN 17081 (8-2017)
Page 3 of 5
ABOUT YOUR EMPLOYER
Business Telephone Number
Name of Business as Reported on the North Dakota Secretary of State Website
Mailing Address on Record with ND Secretary of State (or, for Corporations with headquarters outside of ND, provide the
mailing address for the payroll contact):
Address
City
ZIP Code
State
Business Website
Business Email Address
Business Owner's Name (First, Last)
Business Owner's Telephone Number
Business Owner's Address
City
State
ZIP Code
Supervisor's Name (if different)
Supervisor's Telephone Number
Supervisor's Address
City
State
ZIP Code
WAGE CLAIM INFORMATION
You may submit a claim for the following reasons:
1) you were paid improperly (not paid for time worked, overtime, minimum wage, vacation time, bonus or commission); or
2) your employer made an unauthorized deduction from your paycheck.
Complete the following sections only if applicable and attach the records requested below. In order for the Department to
accept your claim, you must be specific in your explanation of your claim and attach documentation to support your claim
below.
Wages Owed/Final Paycheck/NSF Check
Do you believe your employer failed to pay you for work performed (for example, you did not receive your final paycheck)?
Yes
No - If yes, all questions below required to be answered:
Briefly describe why you believe you are owed wages
Hourly Rate
Amount Claimed
Hours Worked and Not Paid
Did you punch in/out for your work? ("Did you track your hours?")
Yes - attach records indicated below
No - If no, proceed to next question
Describe your 7-day Work Week Used to Calculate Overtime (for example, Monday through Sunday)
Attach copies of payroll records such as pay stub, work schedule, time cards, and other documentation of basis of pay as
applicable, such as trip tickets, per piece rates, etc. If paid with check returned NSF/closed, attach evidence such as
returned check or bank statements. Any originals will not be returned.
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Parent category: Legal