Form Sfn 17081 - Claim For Wages (Page 4 of 5) in pdf

Form Sfn 17081 - Claim For Wages Page 4

SFN 17081 (8-2017)

Page 4 of 5

Overtime Owed

Do you believe you earned, but were not paid overtime wages (for example, you worked over 40 hours in a workweek, yet were

not paid overtime rate for hours worked over 40)?

Yes

No - If yes, all questions below required to be answered:

Briefly describe why you believe you are owed overtime

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. Also attach your job description. Any originals will not be returned.

Failure to Pay Minimum Wage

Do you believe you were not paid at least minimum wage for hours worked?

Yes

No - If yes, all questions below required to be answered:

Briefly describe why you believe you were not paid minimum wage

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. Any originals will not be returned.

Bonus or Commission

Do you believe you earned a bonus or commission, but were not paid?

Yes

No - If yes, all questions below required to be answered:

Briefly describe why you believe you earned, but were not paid a bonus or commission

Amount Claimed

Attach copies of payroll records such as pay stub, work schedule, time cards, production or sales records, bonus and/or

commission plan document, offer letter, employment agreement; company policy relating to bonuses and/or commissions.

Any originals will not be returned.

Form Sfn 17081 - Claim For Wages Page 4