Form Wh-1 - Wage / Benefit Claim Form

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Wage and Hour Program
For Office Use Only
P.O. Box 488
Vermont Department of Labor
Montpelier, VT 05601-0488
Claim #:
Telephone: 802-828-0267
WAGE / BENEFIT CLAIM FORM
FAX: 802-828-4198
Entered:
E-Mail: Labor.wagehour@vermont.gov
WORKER'S INFORMATION
Worker's Name: ____________________________________ SS #: ________________ Telephone #: ______________________
Worker's Mailing Address: ________________________________________________
Are you a High School student? _______
BUSINESS INFORMATION
Business Name: _________________________________________ Business Telephone #: ___________________
Business Owner’s Name: ______________________________ Job Title: ________________________________
Business MAILING Address: ____________________________________________________________________________
Business PHYSICAL Address: __________________________________________________________________________
Start Date of Employment: ___________________ Last Day Worked: __________________ Still Employed? _________
Rate of Pay $ _________ (per day, week, year, salary)
Total Gross Amount Due: ____________
Claim for (check all that apply):
Unpaid Wages
Unpaid Overtime
Improper Deduction
Unpaid Benefits
Indicate breakdown of unpaid wages and overtime below, for improper deductions or unpaid benefits, please provide
details supporting your claim.
Total Amount of
Number of
Amount
Pay Period
Date Payment
Wages Owed
Hours Unpaid
Unpaid
Ending Date
was Due*
This Pay Period
Regular
Overtime
Regular
Overtime
* Cannot be greater than 2 years old.
I hereby certify that, to the best of my knowledge, these statements are true. I understand that a copy of this claim, and
any materials that I submit to the Wage and Hour Program relative to this claim, will be forwarded to my employer and/or my
employer's representative.
Signature: ____________________________________________________
Date: ________________________
Equal Opportunity is the Law
The State of Vermont is an Equal Opportunity/Affirmative Action Employer. Applications from women, individuals with disabilities, and
people from diverse cultural backgrounds are encouraged. Auxiliary aids and services are available upon request to individuals with
disabilities. 711 (TTY/Relay Service) or 802-828-4203 TDD (Vermont Department of Labor).
WH-1 (06/17)

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