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Statement of Claim for Wages
Statement of Claim for Wages
Use:
Statement of Claim for Wages
to report or recover missed or unpaid wages
Workplace Standards Complaint Form
to report non-wage related workplace issues
eWage Case Information
Case Type
*
Statement of Claim for Wages
Workplace Standards Complaint
Anonymous Filing
CLAIMANT INFORMATION - Fill In
First Name
Last Name
*
SSN #
Tax ID#
Sex
Female
Male
Address (Number and Street)
(City or Town)
(State)
(Zip Code)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Not Given
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Telephone Number
Type of Work Done / Occupation / Title
I prefer to receive an acknowledgment letter by:
Email
Regular Mail
Email Address
Name of Person in charge
Title (e.g.: owner, president, manager)
Supervisor DOB
Did you work at the business address listed below?
No
Yes
Please provide location:
Number of Hours Per Week
Date Hired
First Wage Rate
Last Wage Rate
Quit / Layoff
Discharged
Still Employed
Date of Separation
Reason for the Separation
Wages Claimed From (Date)
To (Date)
At the Rate of (Hour, Day, Week, etc.)
Total Amount Claimed
CLAIMANT INFORMATION - Anonymous
Filing anonymously will result in no contact from Wage & Workplace Standards Division
Last Name
*
Date
ANONYMOUS
Type of Work Done / Occupation / Title
Name of Person in charge
Title (e.g.: owner, president, manager)
Did you work at the business address listed below?
No
Yes
Please provide location:
Cf Numb Hours Per Week
Cf Numb Hours Per Week
Cf Numb Hours Per Week
Cf Numb Hours Per Week
Cf Numb Hours Per Week
Number of Hours Per Week
Date Hired
Quit / Layoff
Discharged
Still Employed
Date of Separation
Reason for the Separation
CLAIM DETAILS
Please check the reason(s) you are filing this claim:
(Use the button on the right to select multiple reasons)
Bonus
Bounced paycheck
Commission(s) not received or incorrect (please provide detailed information and employment agreement if available)
Final paycheck(s) not received or incorrect
Illegal deductions
Improperly classified as an independent contractor
Minimum Wage
Non-Payment of Prevailing Rate on Public Works Project (please provide project name(s) on back of this form
No paystub
Not paid for all hours worked
Overtime wages (time and one-half)
Vacation Pay upon termination (please provide written policy)
All
None
Visible
Inverse
Cancel
Lookup List
Breastfeeding in the workplace
Child Labor
Drug Testing
Electronic Monitoring
Meal Periods
Personnel Files
Paid Sick Leave (C.G.S. 31-57s)
Smoking Outside the Workplace
Smoking in the Workplace
Use of Credit Report
Bonus
Bounced paycheck
Commission(s) not received or incorrect (please...
Converted
Final paycheck(s) not received or incorrect
Illegal deductions
Improperly classified as an independent contractor
Minimum Wage
Non-Payment of Prevailing Rate on Public Works ...
No paystub
Not paid for all hours worked
Overtime wages (time and one-half)
Ley de seis días
Amamantar (dar el pecho) en el lugar de trabajo
Estar en la lista negra
Pago extra (bonus)
Uso de un informe de credito
No recibo de talonario
Cancelación de seguro sin notificación previa
No pudo cobrar el cheque de pago
Comisión(es) no recibida(s) o incorrecta(s)(por...
Deducciones ilegales
Prueba de drogas
Monitoreo electrónico
Cheque de pago final no fue recibido o no es co...
Archivos de recursos humanos
Clasificado indebidamente como contratista inde...
Detector de mentiras
Salario mínimo
Horas de comida
No fue pagado por todas las horas trabajadas
Salario de horas extras(a razón de una vez y media
Licencia pagada por enfermedad (A. P. 11-52 sol...
No pagar el salario imperante en un Proyecto de...
Fumar en el lugar de tabajo
Fumar fuera del lugar de trabajo
Pago de vacaciones al ser terminado(por favor, ...
Soplón
Trabajo de menores
Vacation Pay upon termination (please provide w...
Work/Services Performed
Explain why you believe the employer owes you wages. List the dates and hours for which you believe wages are due.
Did you ask the employer for the money you believe is due?
No
Yes
Name of person you asked
Title of person you asked
If No, why
COMPLAINT ISSUE
Please check the reason(s) you are filing this claim:
Breastfeeding in the workplace
Child Labor
Drug Testing
Electronic Monitoring
Meal Periods
Personnel Files
Paid Sick Leave (C.G.S. 31-57s)
Smoking Outside the Workplace
Smoking in the Workplace
Use of Credit Report
All
None
Visible
Inverse
Cancel
Lookup List
Breastfeeding in the workplace
Child Labor
Drug Testing
Electronic Monitoring
Meal Periods
Personnel Files
Paid Sick Leave (C.G.S. 31-57s)
Smoking Outside the Workplace
Smoking in the Workplace
Use of Credit Report
Bonus
Bounced paycheck
Commission(s) not received or incorrect (please...
Converted
Final paycheck(s) not received or incorrect
Illegal deductions
Improperly classified as an independent contractor
Minimum Wage
Non-Payment of Prevailing Rate on Public Works ...
No paystub
Not paid for all hours worked
Overtime wages (time and one-half)
Ley de seis días
Amamantar (dar el pecho) en el lugar de trabajo
Estar en la lista negra
Pago extra (bonus)
Uso de un informe de credito
No recibo de talonario
Cancelación de seguro sin notificación previa
No pudo cobrar el cheque de pago
Comisión(es) no recibida(s) o incorrecta(s)(por...
Deducciones ilegales
Prueba de drogas
Monitoreo electrónico
Cheque de pago final no fue recibido o no es co...
Archivos de recursos humanos
Clasificado indebidamente como contratista inde...
Detector de mentiras
Salario mínimo
Horas de comida
No fue pagado por todas las horas trabajadas
Salario de horas extras(a razón de una vez y media
Licencia pagada por enfermedad (A. P. 11-52 sol...
No pagar el salario imperante en un Proyecto de...
Fumar en el lugar de tabajo
Fumar fuera del lugar de trabajo
Pago de vacaciones al ser terminado(por favor, ...
Soplón
Trabajo de menores
Vacation Pay upon termination (please provide w...
Work/Services Performed
Explain why you believe the employer owes you wages. List the dates and hours for which you believe wages are due.
EMPLOYMENT INFORMATION
Business Name (Employer)
*
Business Telephone No
Business Street Address (not a P.O. Box)
*
(City or Town)
*
(State)
*
(Zip Code)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Not Given
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other Business Name(s) that might be used by employer
ATTACH / UPLOAD DOCUMENT (PDF, Word, Excel, RTF, GIF, JPEG, JPG)
Document Type
STATEMENTCLAIMWAGES - Statement of Claim For Wages
Upload (PDF, Word, Excel, RTF, GIF, JPEG, JPG)
Date Received
ATTACH / UPLOAD DOCUMENT (PDF, Word, Excel, RTF, GIF, JPEG, JPG)
IMPORTANT
PLEASE NOTE THE FOLLOWING :
If you are complaining that you did not receive a final paycheck, you must physically report to the normal place you are paid and attempt to obtain payment yourself. Making phone calls and/or sending friends or relatives to obtain payment are not sufficient. If you do not attempt to obtain payment yourself, we will not investigate your claim.
This Division has jurisdiction over wage issues and violation of Connecticut’s labor laws. We cannot assist you in obtaining payment for time not worked (holiday pay, severance pay, etc.), or for expenses, tax issues, or pension plan issues. We may be able to assist you in obtaining payment for unused fringe benefits such as vacation pay, but only upon separation of employment. Most of the laws enforced by this office are listed on our website. Unless a state stature has been violated, this office has No Jurisdiction.
The following agencies may be able to assist you for employment-related problems:
Discrimination/Sexual Harassment……CT Commission on Human Rights & Opportunities
Pensions/COBRA Benefits………………….US Department of Labor, Employer Benefits Security Administration (617)565-9600
In submitting this form, I hereby attest to the following:
That this is a true statement of wages due me to the best of my knowledge and belief. I hereby assign all wages and all penalties accruing because of their non-payment, and all liens securing them to the Labor Commissioner of the State of Connecticut to collect in accordance with the law.
That I authorize the mailing at my own risk of any money paid on this claim.
That I authorize the Labor Commissioner or any person authorized by the Labor Commissioner to approve a proposed compromise adjustment or settlement of this claim, unless I object in writing within ten days after notification to me at the address given by me to the Labor Commissioner. I understand my claim may be reassigned back to me to pursue in small claims court or through a private attorney.
By submitting this form: I authorize the deduction of the cost of mailing any certified payments if collection of wages exceeds $15,000.
PLEASE NOTE
**If you want a copy of your claim, print it before submitting the form**
Submit