Wage Claim Form

Your Name (required)

City

State

Phone

Your Email (required)

How are you paid?
HourlySalaryOther

Do you work more than 40 hours per week?
Yes No 

How much are you paid hourly/salary?

What type of industry do you work?

What is your job title?

Are you an independent contractor?
Yes No Not Sure 

Are you considered exempt from overtime?
Yes No Not Sure 

If so, why?

Other facts about your situation