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

Form Sfn 17081 - Claim For Wages Page 5

SFN 17081 (8-2017)

Page 5 of 5

Vacation Pay Owed

Do you believe you have not been properly paid for vacation time (PTO, etc.)

Yes

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

Briefly describe why you believe you earned, but were not paid for vacation time

Amount Claimed

Explanation for Amount Claimed (how did you reach this conclusion)?

Attach copies of payroll records such as time sheets and pay stubs showing accrued vacation balance, company policy

regarding vacation pay, PTO, etc., and any other documentation supporting your claim. Any originals will not be returned.

Unauthorized Deduction

Do you believe your employer improperly deducted money from your paycheck without your authorization?

Yes

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

Briefly describe why you believe your employer improperly deducted money from your paycheck

Amount Claimed

Attach copies of payroll records such as pay stubs showing deduction(s), company policy regarding deductions, written

authorizations, and any other documentation relating to deductions. Any originals will not be returned.

Total Amount Claimed (add all sections above)

Signature

Date

Form Sfn 17081 - Claim For Wages Page 5