Wage Claim Form Page 3
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1
2
3Did you ask for your wages?
Yes
No
If yes, employers response:
List names, addresses, and phone numbers of any witnesses who can support your claim:
Please state your understanding of your work and pay agreement, how you calculated back wages, and why you are due these wages. Attach
copies of any documents you have which will help you prove your claim.
I certify that the above foregoing facts and circumstances are true and correct to the best of my knowledge. I agree to not contact my
employer or former employer about this claim directly and to refer any inquiries to the Arkansas Department of Labor/Labor Standards
Section.
Claimant Signature:
Date:
Submit by Email
Print Form To Mail
Page 3 of 3
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Parent category: Legal