Statement of Claim for Wages

Statement of Claim for Wages

a59535469796229003
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*

CLAIMANT INFORMATION - Fill In 

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First Name Last Name* SSN # Tax ID# Sex
         
Address (Number and Street) (City or Town) (State) (Zip Code)
       
Telephone Number Type of Work Done / Occupation / Title
I prefer to receive an acknowledgment letter by:
Name of Person in charge Title (e.g.: owner, president, manager) Supervisor DOB
Did you work at the business address listed below?
Number of Hours Per Week Date Hired First Wage Rate Last Wage Rate
Date of Separation Reason for the Separation
Wages Claimed From (Date) To (Date) At the Rate of (Hour, Day, Week, etc.) Total Amount Claimed

CLAIM DETAILS 

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Please check the reason(s) you are filing this claim:
(Use the button on the right to select multiple reasons)
Multiple
 
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?

EMPLOYMENT INFORMATION 

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Business Name (Employer)* Business Telephone No
 
Business Street Address (not a P.O. Box)* (City or Town)* (State)* (Zip Code)
       
Other Business Name(s) that might be used by employer

ATTACH / UPLOAD DOCUMENT (PDF, Word, Excel, RTF, GIF, JPEG, JPG) 

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STATEMENTCLAIMWAGES - Statement of Claim For Wages 

files

 
ATTACH / UPLOAD DOCUMENT (PDF, Word, Excel, RTF, GIF, JPEG, JPG)

IMPORTANT

PLEASE NOTE THE FOLLOWING :

  1. 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.
  2. 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.
  3. 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**