Wage Claim Form Page 2
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1
2
3Mail To:
Arkansas Department of Labor
Arkansas Dept of Labor
WAGE CLAIM FORM
Labor Standards Section
10421 West Markham
READ ALL INSTRUCTIONS PRIOR
Little Rock, Arkansas 72205-2190
TO COMPLETING
Ph 501-682-4500 fax 501-682-4506
Claim #_____________________
CLAIMANT INFORMATION (Please Print Clearly)
Your Name:
Amount of Claim: $
Max $2000.00
Mailing Address:
Phone: (
)_______-_______
Social Security#:_____-____-_______
Street,City,State
Email Address:
Gross Earnings From All Sources Last 12 Months: $
Name Of Nearest Relative:
Phone:
EMPLOYER WHO OWES WAGES
Business Name:
Phone:
Fax:
James Agency
Mailing Address:
Physical Address:
Dates of employment: ___________
to
______________
Dates wages were earned but not paid: ___________
TO
__________
Who hired you?
Direct supervisor name:
Is business still open?
Yes
No
Is business a corporation?
Yes
No
Not Sure
Were you an independent or sub contractor?
Yes
No
If yes,
Is business in bankruptcy?
Yes
No
attach copy of contract if available
Were you paid by the:
Hour
Daily
Weekly
Bi-Weekly
Bi-Monthly
Monthly
Salary
Piece Work
Commission
Other
Pay Rate:
Did the employer keep records of your time?
Yes
No
Did you authorize deductions other than payroll taxes?
Yes
No
Did you keep records of your time?
Yes
No If yes attach copy
If yes, list:
Was this work performed in Arkansas for an Arkansas company?
Type of work performed:
Yes
No
Are you related to the employer?
Yes
No If yes, relationship:
How were you paid?
Check
Cash
Other (explain)
Do you have any of the employer’s property?
Yes
No If yes list:
Was your work agreement
Oral
Written If written attach copy of contract
Do you owe money to the employer?
Are you still working for the employer?
Yes
No
Yes
No If yes amount:________________________________
Has the employer named you in a police investigation involving the business?
Yes
No
Is your claim for vacation pay, bonus, sick, severance, shift differential or holiday Pay?
Yes
No
If yes, attach policy
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