Claim Of Unpaid Wages

SOUTH DAKOTA DEPARTMENT OF LABOR AND REGULATION CLAIM OF UNPAID WAGES Division of Labor and Management | Wage and Hour Division 700 Governors Drive Pierre, South Dakota 57501 Tel: 605-773-3682 Fax: 605-773-4211 dlr.sd.gov Your claim will not be processed if this form is incomplete, is illegible, or if documentation is not attached. Send this completed form to the address above. The South Dakota Department of Labor cannot pursue claims for any wages other than cash wages. Do not include claims for overtime, vacation pay, bonuses, deductions, profit sharing, severance, etc. PRINT OR TYPE ALL ENTRIES EMPLOYEE INFORMATION Employee Name: First Employee Mailing Address: Number & Street Employee Driver's License Number: Employee Date of Birth: Employee Phone Numbers: Home Cell Other City State Zip Middle Last EMPLOYER INFORMATION Employer/Business Name: Address of business: Number & Street Employer/Business Phone Numbers: Home Name(s) of Business Owner(s): Address of Business Owner(s): Number & Street Other Business(es) owned by this business or business owner(s): List the names, position, and address of all people in supervision who had the authority to make decisions about your pay: Name Position: Address (Number, Street, City, State, & Zip) Address (Number, Street, City, State, & Zip) City State Zip City Cell State Fax Zip Name Position: Addresses where work was performed. Use separate page if necessary: Number & Street Address where employer maintains payroll and personnel records, if different from above. City State Zip Number & Street City State Zip American LegalNet, Inc. www.FormsWorkFlow.com While you were working, was this employer serving as a subcontractor? If Yes, name and address of general contractor: Employer is (Check one): Name Yes No Address (Number, Street, City, State, & Zip) Corporation Don't know Partnership Individual Proprietorship If the Employer is a Corporation, complete the following, if you know: Corporate Address: Number & Street Name of Resident Agent Name of President Name of Secretary Name of Treasurer Name of Corporate Manager Number & Street Number & Street Number & Street Number & Street Number & Street City City City City City City State State State State State State Zip Zip Zip Zip Zip Zip TERMS OF EMPLOYMENT Did you work under written contract: Type of work performed: Your specific job title: Start date of employment with Employer: End date of employment with Employer: How did employer compute your pay? If you were paid by the piece or by commission explain: At the time of your unpaid wages, what was your rate of pay? How many days were in your pay period? What was the last day of your pay period? What was your payday? If you are a member of a labor union, provide the name and address of local, national, or international union. Are you still working for this Employer? If No, did you: Explain: Quit? Yes No Get Fired? Laid Off? By the: Hour Week Two weeks Month Yes No If Yes, attach copy SD Claim of Unpaid Wages ­ use additional pages if necessary. Rev. 7/29/16 American LegalNet, Inc. www.FormsWorkFlow.com WAGES CLAIMED Total dollar amount you are claiming (Use the attached Wages Claimed Schedule): Gross: Start Did your Employer deduct any amount from your wages as payment for child support or some other debt? Did you receive any payroll advances? Do these advances offset wages that you claim are owed? Yes No Net: End Period of time for which you claim you were not paid: If Yes, explain, on a separate sheet of paper, in detail the specifics of this deduction and attach any documentation necessary. If yes, how much? _____________ Yes No Yes No Have you demanded payment? Yes No If yes, when? Did the employer agree to pay you? Yes No If yes, how much?_______ When? ____________ Did the employer pay part of your demand? Yes No If yes, how much? ________ What reason did your employer give for not paying your wages? ________________________________________ Your employer does not have to give you your final paycheck until you have returned all property of employer in your possession. Can/Will Employer make a claim that you have not returned all of Employer's property? Yes No Explain Details: What did Employer promise to pay you that was not paid? How did you calculate the amount you claim you are owed? Is there a property dispute? WITNESSES TO YOUR CLAIM: If witnesses SAW or HEARD conversations or other events that support your claim that the wages were promised but not paid, list those witnesses: Name Position Address SD Claim of Unpaid Wages ­ use additional pages if necessary. Rev. 7/29/16 American LegalNet, Inc. www.FormsWorkFlow.com Name Position Address If anyone in management knew or acknowledged that you are entitled to receive wages, list their names and position and corporate title and addresses Name Position Address (Number, Street, City, State, & Zip) Name Position Address (Number, Street, City, State, & Zip) Documentation Of Your Unpaid Wages You must attach copies of all evidence you have to support your claim for unpaid wages. Indicate below which documents you are submitting to support your claim. Be aware that you may be required to produce the originals of any documentation you allege supports your claim. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Time Cards Shift Schedules Attendance Rosters Log Books Personal Time Records Payroll Check Stubs Copies of Bad Checks (NSF) Other Evidence of Payment of Wages W-2 Statements or Other Tax Forms Employee Handbook Written Wage Agreements Statements from witnesses, other than a relative, who have direct knowledge regarding the hours worked and the wage agreement (including daytime telephone number). Career Center Job Order Newspaper Job Advertisement Any other documents that support your employment and amount ot wages. 13. 14. 15. You must complete the Release of Information on the next page. SD Claim of Unpaid Wages ­ use additional pages if necessary. Rev. 7/29/16 American LegalNet, Inc. www.FormsWorkFlow.com RELEASE OF INFORMATION: (REQUIRED) I DO HEREBY AUTHORIZE THE EMPLOYEES OF THE SOUTH DAKOTA DEPARTMENT OF LABOR TO RELEASE THIS INFORMATION TO ANY PERSON INCLUDING THE EMPLOYER HEREIN TO AUTHENTICATE AND TO COLLECT THIS CLAIM. I DO HEREBY SWEAR OR AFFIRM THAT THE FOREGOING AND ATTACHED INFORMATION IS THE TRUTH, THE WHOLE TRUTH, AND NOTHING BUT THE TRUTH TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THAT IF I HAVE FALSIFIED THE AMOUNT DUE ME OR IF I INTENTIONALLY ATTEMPT TO DEFRAUD THE