1. Quick screening (DLSE preliminary questions)

Is your claim about a public works project? *

Yes

Have you filed a retaliation complaint with the Labor Commissioner? *

Yes

Date filed *

Is there a union contract / CBA covering your employment? *

Yes

Provide a copy

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Are other employees also filing wage claims against this employer? *

Yes

I don't know

7. Employment details

Do you need an interpreter? *

Yes

Which language?

Advocate/Attorney assisting?

Yes

Advocate Name

Organization Name

Advocate Phone

Mailing Address

3. Claimant (employee) information

Full Name *

Phone *

Date of birth

Email *

Address

Street Address *

City *

State *

Country *

Postal Code *

Alternative Contact

Alternate Contact's Name

Relation with them

Alternate Contact's Phone

Alternate Contact's Email

4. Employer / business information

Employer identity

Employer / Business name(s) *

Employer's Phone *

Employer Email *

Employer vehicle license plate # (if known)

Address

Business address *

Address where you worked (if different)

Is the worksite address different from the business address? *

Yes

Share that address

Management / responsible contacts (DLSE basic)

Name of person in charge

Job title/position

6. Extra employer details

Primary industry

Is the employer still operating normally? *

Yes

Not sure

Recently closed / sold major assets / bankruptcy threats? *

Business name changes during/after employment? *

Other potentially responsible individuals (owners/officers/managers) + how responsible

7. Employment details

Date of hire *

Who hired you (name + title, if known)

Your job title(s) *

Main job duties *

Who paid you? *

Who supervised you day-to-day? *

Who set your schedule? *

How were your hours tracked? (timeclock/app/paper/other) *

If someone else recorded your hours: full name + title

Were you ever told to sign an inaccurate timecard?

Yes

11. Please provide the following documents

Pay stubs / wage statements

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Copies/photos of checks (front/back), including bounced checks

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Time records (clock-in/out), schedules, screenshots of apps

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Any written pay agreements (offer letter, texts/emails about pay, commission plan)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Expense receipts/mileage logs (if reimbursement claim)

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Any termination/quit messages + final pay proof

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

Names/contact info for witnesses or coworkers also affected

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

If union contract applies: copy of CBA

PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF

1. Quick screening (DLSE preliminary questions)

7. Employment details

3. Claimant (employee) information

Alternative Contact

4. Employer / business information

Employer identity

Address

Management / responsible contacts (DLSE basic)

5. Business descriptors (DLSE basic)

6. Extra employer details

7. Employment details

8. Employment status + separation (final wages)

9. How you were paid (and problems like bounced checks)

Extra pay details commonly asked online

Provide your best estimate of start/end + meal periods in your typical workweek.

If you’re claiming unpaid wages/overtime or meal/rest violations: complete DLSE Form 55 (use best estimate and any records you kept).

10. Pay structure

11. Please provide the following documents