1. Quick screening (DLSE preliminary questions)
Is your claim about a public works project?
*
Yes
No
Have you filed a retaliation complaint with the Labor Commissioner?
*
Yes
No
Date filed
*
Is there a union contract / CBA covering your employment?
*
Yes
No
Provide a copy
PDF, DOC/DOCX, XLS/CSV, JPG/JPEG, PNG, GIF
Are other employees also filing wage claims against this employer?
*
Yes
No
I don't know
7. Employment details
Do you need an interpreter?
*
Yes
No
Which language?
Advocate/Attorney assisting?
Yes
No
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
*
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
No
Share that address
Management / responsible contacts (DLSE basic)
Name of person in charge
Job title/position
5. Business descriptors (DLSE basic)
Type of business (e.g., restaurant, construction, trucking)
*
Type of work you performed (short description)
*
Approx. total # employees during your employment
*
Employer still in business?
*
Yes
No
I don't know
Employer type (if known)
Corporation
Individual
Partnership
LLC
LLP
Don't know
Is this claim related to being misclassified as an independent contractor?
*
Yes
No
6. Extra employer details
Primary industry
Is the employer still operating normally?
*
Yes
No
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
No
8. Employment status + separation (final wages)
Check one
*
Still working
Quit
Discharged
Other
Quit date
Did you give at least 72 hours notice?
Yes
No
Final wages paid?
Yes
No
Add date when final wages paid
Date of Discharge
Final Wages after dicharge
Paid
Not Paid
Payment Date
9. How you were paid (and problems like bounced checks)
How were your wages paid?
Cash
Check
Both
Other
Did any paychecks bounce?
Yes
No
List dates/amounts
Extra pay details commonly asked online
Were wages always paid on the employer’s regular payday?
Yes
No
Did you receive itemized pay stubs with cash/check payments?
Yes
No
Any off-the-books payments?
Yes
No
Work schedule
Which best describes your schedule?
Usually the same each week
Varied/irregular
Provide your best estimate of start/end + meal periods in your typical workweek.
Start (am/pm)
End (am/pm)
1st meal start
1st meal end
2nd meal start
2nd meal end
Split shift
Yes
No
1st shift ended
2nd shift ended
If you’re claiming unpaid wages/overtime or meal/rest violations: complete DLSE Form 55 (use best estimate and any records you kept).
Any periods you did not work (laid off/vacation/sick/business closed):
Holidays you did not work
10. Pay structure
Primary pay type(s)
Hourly (single rate)
Hourly (multiple rates)
Salary
Piece rate
Commission
Paid /hr
$
For Tasks/hr
Promised /hr
$
Tasks/hr
Amount Paid
$
Paid Per
Day
Week
Every 2 week
Month
Semi-Monthly
Amount Promised
$
Piece rate details (if any)
Describe units + Rate + How tracked
Commission details (if any)
rate/plan, when earned, when paid
Tips (if any)
Pool? Kept by employer? Amounts?
Bonuses promised (if any)
Type + Amount + Dates
Claims being made & Amounts
For each claim, please share start date, end date, and amount earned/claimed.
Check all that apply
Regular wages (non-overtime)
Overtime wages (incl. double time)
Meal period wages
Rest period wages
Split shift premium
Reporting time pay
Commissions
Vacation wages
Business expenses (reimbursements)
Unlawful deductions
Paid sick leave
Supplemental Paid Sick Leave
Other
Subtotal (add all amounts claimed)
$
Total amount paid already
$
Grand total owed (subtotal – paid)
$
Penalties/damages (check if claiming)
Waiting time penalties (LC §203)
Bounced check penalties (LC §203.1)
Late payment penalties (LC §210)
Liquidated damages for late payment wages (LC §1194.2)
Compensatory damages for willful misclassification (LC §226.8)
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