Unpaid Wages or Overtime

1 Your Contact Information

2 Employer & Work Details

3 Statuses & Legal Actions

4 Owed Wages & Details

• 1. Your Contact Information

• Your Name*
  First Last
• Your Phone*
• Your Email*

• 2. Employer & Work Details

• Name of Company/Employer*
• Address of Work Location*
• Job Title*
• Date Started Working For Company/Employer*
  Date Format: MM slash DD slash YYYY
• Date Last Worked For Company/Employer*
  Date Format: MM slash DD slash YYYY
• Date Last Paid By Company/Employer*
  Date Format: MM slash DD slash YYYY
• Number of Days worked per week*
• Hours Worked Per Day*
• How Much Do You Get Paid?
• Paid By:
  • Hour
  • Salary
  • Other
• Does Company have more than 15 employees?*
  • Yes
  • No
• Does Company have more than 50 employees?*
  • Yes
  • No
• Do you work for the government?*
  • Yes
  • No
• Are you part of a union?*
  • Yes
  • No
• Do you have an Employment Contract that Guarantees employment for 1 or more years?*
  • Yes
  • No
• Do you have contact information for Human Resource department or company management?
• Name of Supervisor

• 3. Statuses & Legal Actions

• Complaints
• Have you filed a Complaint with the Company/Employer internally?*
  • Yes
  • No
• Lawsuits
• Have you filed a lawsuit?*
  • Yes
  • No
• Dates & Deadlines
• Do you have any deadlines?*
  • Yes
  • No
• Date of Deadline
  Date Format: MM slash DD slash YYYY
• Bankruptcy
• Have you or will you file for Bankruptcy?*
  • Yes
  • No
• Date of Bankruptcy
  Date Format: MM slash DD slash YYYY
• Unemployment
• Have you filed for Unemployment Benefits?*
  • Yes
  • No
• What is the Unemployment Status?
• Date
  Date Format: MM slash DD slash YYYY
• Disability Benefits
• Have you filed for disability benefits?*
  • Yes
  • No
• Disability Date
  Date Format: MM slash DD slash YYYY
• Retirement & Pension
• Do you have a retirement date or pension?*
  • Yes
  • No
• Retirement/Pension Date
  Date Format: MM slash DD slash YYYY

• 4. Owed Wages & Details

• Having issues with: (check all that appy)
  • I was not paid at all for at least some hours I worked:
  • I was paid less than minimum wage
  • I was not paid for overtime hours when I worked more than 40 hours in a week
  • I was not given my last pay check
  • I was required to work through breaks
  • I was not paid at rate promised
  • I was not paid commissions or bonus
  • I did not receive earned sick/vacation pay
  • I was not given all my tips
  • Management changed my hours
• How much money owed?
• Rate of Pay or Salary?
• Is the company still open?
  • Yes
  • No
• What is the reason the company gave you for not paying?
• How much do you make per week?
• How much do you make every 2 weeks?
• How much do you make per month?
• How much of your wages comes from bonuses, commission or tips?
• Your Daily Job Duties?
• Do you hire or fire employees?
• Do you set schedules for other employees?
• Do you set schedules for other employees?
• Do you reprimand employees and enforce or set company policy?
• Do you open or close a store?
• Do you handle money for the company?
• Do you clock in and out of work?
• Do you keep records of hours worked?
• Your regular work schedules?
• How many hours worked per week?
• How many hours did you work but did not get paid for?
• How much owed for PTO, vacation pay, or commissions?
• How long has company been open?
• Does company have more than 20 employees?
• Does company have more than 50 employees?
• Have you requested the unpaid wages in writing via text message or email or letter?
• What county did you work in? If more than one, name of counties
• Do you drive a truck?
• Do you do deliveries?
• Do you work for tips? What is the least amount of tips you get in 1 week? What is your base salary or pay? What employees get to share in the tips? Dishwasher? Cook? Manager?