INSTRUCTIONS FOR FILING A WAGE CLAIM

LABOR COMMISSIONER, STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT

!"#$%&'$!( " # *(% *!+!", - .-,/ '+ -!0

1) Fill out and&submit the “Initial Report or&Claim”&Form (DLSE Form 1). If you do not understand how to fill out any part of

the Form, please read the “,1234 56 '6789452:; !:252<9 %486=5 6= '9<27 *6=7” (attached to these Instructions).

Along with your completed “Initial Report or Claim” Form,&submit these <332526:<9 >+#/)*6=7? if any of the following

situations&apply to you:

If your @6=A B61=? <:3C6= 3<D? 6E @6=A F<=243 6= @4=4 2==4;19<=G <:3 yo u are cla iming 1:8<23)@<;4? HE6=

6F4=5274 6= :6:I6F4=5274 B61=? @6=A43J 6= 7 4<9 <:3)=4?5)84=263 F269<526:?, th en al so fill ou t a nd su bm it the

>+#/ *6=7 KK. Fill out the DLSE Form 55 as best as you can,&based on your best estimate of hours worked or any of

your own records that you kept of your hours worked.

If you are claiming L6772??26: 8<D, then also fill out and submit the >+#/ *6=7 MKK.

If you are claiming F<L<526: @<;4?, then also fill out and submit the >+#/ “N<L<526: O<D #LB43194” form.

If you are represented by an attorney, you may submit&a calculation prepared by your attorney in lieu of&the above

computation forms.

Along with your completed “Initial Report or Claim” Form, submit 6:4 '(OP of the following documents,&if you have them

(>( "($)#/">)(%!,!"-+ >('&0/"$#JQ

$274 =4L6=3?R Provide a COPY of any of your own records you kept&of the hours and dates you worked that&you

believe support your claim. This could include, for example, your notes, journals, diaries, or calendars in&which you

marked your hours worked.

O<DLB4LA? <:3)O<D #51S?R Provide a COPY of any paychecks and&pay stubs&you received showing the wages&you

were paid during your claim period.

>2?B6:6=43 H6= TU61:L43VJ O<DLB4LAH?JR If you were paid with a paycheck that&could not&be cashed by you

because your employer has no account with the bank&or insufficient funds in&the account from which the check&was

drawn,&provide a COPY of any such dishonored check(s) or other documentation from the bank that&indicates the

check could not be cashed.

"652L4 6E /7896D74:5 !:E6=7<526:R Provide a COPY if you&received&a Notice from your employer after January&1,

2012 that indicates your basic employment information including your rate of pay, any overtime rate of pay,

whether you were paid by the hour, shift, day, week, salary, piece, commission, or otherwise, and your regular

payday.& Your employer may have called this a “Notice to Employee” and may reference the Labor Code Section that

applies, Section 2810.5.

NOTE: It is the employer’s

legal res p o n s i b ili ty to k e e p a c c u r a te e mployee t ime and pa y r o ll r e c o rd s ,&a nd to provi d e

employees&with pay stubs&each time&they are&paid (or&at least semimonthly). In order&to file&a claim, you are&not

required to keep your&own time&records&or&to have&the&documents&above. These&documents&are&being requested only

if you have them because they may help DLSE better understand your claim.

4) If your employment&was covered by a 1:26: L6:5=<L5, provide a copy of your Collective Bargaining Agreement.

.W-$ $( /XO/'$)-*$/%)P(& *!+/ P(&%)'+-!0

1) #4559474:5 '6:E4=4:L4R In most&cases , you w ill re ceive a No tice from the La bor C om missio ner settin g a date an d time for

a “Conference” in which DLSE will discuss your claim with you and whether your claim has a legal basis to& proceed. At the

Conference, you and&your employer will have an opportunity to&discuss settlement of your claim. For the Conference, you

do NOT need&to&bring any witnesses, but be prepared&to&discuss whether you have any witnesses who&can testify for you at

a hearing, and generally&what they&will testify&about (if your claim does not settle). Bring&a L68D (:65 5B4 6=2; 2: <9) o f any

document that supports your claim, but do not bring documents you have already submitted&with&the Initial Report or

Claim Form.

2) W4<=2:;R If your claim does not&settle at&the Confere nce an d has a leg al ba sis to proc eed to a hea ring, y ou w ill receive a

Notice from the Labor Commissioner setting a date and time for a hearing on your claim. You should be prepared to

present evidence to prove your claim (for example, your testimony, the testimony of any witnesses&if you have any

witnesses, and/or documents if you have supporting documents). Therefore, you should be prepared to bring witnesses

and documents if you have them. If you have documents that support your claim,&bring the 6=2;2:<9 36L174:5? 891? 5@6

?45?)6E L6824? to the hearing.& At the end of the hearing,&the hearing officer will explain what will happen next.

LABOR COMMISSIONER, STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT

Preliminary Questions

Public Works. $% &'()*+&& *, -*,'&, &'()*+&& ./%!-0)& / .*'()/0%1 -*, (,&2/0)0%3 4/3&5 16/1 4&,& %*1 (/07!*% / (89)0. 4*,:5

(,*;&.1# <=89)0. 4*,:5> /5 7&-0%&7!0%!?/9*, @*7& A&.10*%5 "BCD 1*!"BCD#E 0%.)87& <.*%51,8.10*%F /)1&,/10*%F 7&'*)010*%F

0%51/))/10*% F *, ,&(/0, 4*,: 7*%& 8%7&, .*%1,/.1 /%7!(/07!-*, 0%!46*)& *, 0%!(/,1 *81 *- (89)0. -8%75#> G- +*8 4 * ,: &7 *% / (89)0.

4*,:5 (,*;&.1F +*8 56*8)7 AHI= 6&,&#! J* %*1 -0))!*81 1605 -*,' 981 0%51&/7F ( )&/ 5& -0))!*81 16& PWD1&claim form (entitled&“Public

Works – Initial&Report”)# K*8 ' /+ /5: J?AL!51/-- -*, / .*(+ *- 16& =MN"!-*,' *, 7*4%)*/7 01 /1O

611(OPP444#70,#./#3*2P7)5&PQ*4H*R0)&=M@*'()/0%1#61'

Retaliation. G1 05 8%)/4-8 )!-* , /% &'()*+&, 1* ,&1/)0/ 1& *, 705. ,0'0%/1& /3/0%51 + * 8 S-*,!&T/'()& F -0,&F 16,&/1&% 1* -0,&F!7&'*1&F

585(&%7 *, 705.0()0%& + * 8 U 9&./85& +*8 .*'()/ 0% /9*81 +*8, 4*,:0%3 .*%7010* % 5F!-0)& / 4/ 3 & .)/0' 4016 J? A LF!* , (,*207&

0%-*,'/1 0* % 1* J?A L *, /%+ 3*2&,%'&%1 /3 &% . + / 9 * 8 1 +*8, 4*,:0%3!.*%7010*%5# @6&.: 16& <K L A > 9*T 0- +*8 6/ 2& -0)&7 /

,&1/)0/10*% .*' ( )/0% 1!4016 16& ?/9*,!@ *''0550*%&,F / % 7 &%1&,!16& date&you&filed&the&complaint. G- +* 8 6/2& % * 1 -0)&7 /

,&1/)0/10*% .*' ( )/0% 1!98 1!4* 8 )7 )0:& 1* -0)& *%&F +*8!'/+ /5: J?AL 51/-- -*, / .*(+ *- 16& ,&1/)0/10*%!.*'()/0%1 -*,' *, 7*4%)*/7

01 /1O 611(OPP444#70,#./#3*2P7)5&PQ*4H*R0)&RetaliationComplaint#61'

E# Union Contract? @6&.: <KLA> 0- +*8, & '()*+' &% 1 4/5 .*2&,&7 9+ / union&contract. G- + * 8 .6&.:&7 <KLAF> 16&% /11/.6 / .*(+ * -

16& @*))&.102& V /,3/ 0%0%3 $3,&&'&%1#

W# Other Employees Filing Wage Claims? @6&.: <KLA> 0- +*8 : % * 4 16/1 * 1 6 & , &'()*+ & &5 /,& -0)0%3 4/3& .)/0'5 /3/0%51 +*8,

&'()*+&,#

PART 1: Language Assistance & Representation

X /# Interpreter Needed? @6&.: <KLA > 0- +*8, (,0'/,+ )/%38/3 & 05 %*1 L%3)056 /%7 +*8 4/%1 /% 0%1& , ( ,& 1& , 1* /5505 1 +*8#

9# Language. G- +*8 .6 & . :& 7 <KLA> 1* V* T X/ 0%70. / 10% 3 16/1 +* 8 %&&7 /% 0%1& ,( , &1 & ,F!& % 1& , 16& )/% 3 8 / 3 & *- 16& 0%1&,(,&1& , %&&7& 7 #

Y /#

Name of Advocate. G- +* 8 /,& 9& 0% 3 /55051&7 4016 +*8, .)/0' 9+ / )/4+&, *, *16 & , /72*./1 &F!& % 1 & , 16& name&and&organization *-

16& (&,5*% 46* 05 /550510%3 +*8#

9# Phone&Number of Advocate. G- +*8 /, & 9&0%3 /55051&7 4016 +*8 , .)/0' 9 + / )/4+ &, *, *16 &, /72*./1 &F &%1&, 16& phone number

/1 460.6 +*8

, /7 2*./1&!./% 9&!.*%1/.1&7#

.# Mailing Address of Advocate. G- +*8 /,& 9&0% 3 /55051&7 4016 +*8, .)/0' 9+ / )/4+&, *, *16 & , /72*./1 & F!&% 1 & , 16& mailing

address *- +

*8, )/4+&, *, *16&, /72*./1&# G%.)87& 16& 51,&&1 %/'& /%7 %8'9&,F /5 4 &)) /5 /%+!-)**, *, 5801& %8 '9 &,F .01+F 51/1&F

/%7 Z0( .*7&# J?AL!40)) '/0) .*(0&5 *- 0%-*,'/10*% ,&)/1&7 1* +*8, .)/0' 1* 16&!/77,&55 *- +*8, /72*./1&!16/1 +*8 &%1&, 6&,&#

PART 2: Your Information

B# Your First Name. L%1&, +*8 , first&name#

[# Your Last Name. L% 1& , +*8, last name.

\# Your Home P

hone Number. L%1&, +*8, home&telephone&number, with&ar

ea code#

"D# Other Phone Number. L%1 &, 16& (6 * % & %8'9&,F!4016 /,&/ .* 7 &F!* - another phone /

1 460.6 J?AL!./% ,&/.6 +*8 S-*, &T/'()&F /

cell phone 16/1 +* 8 85&U#

""# Your Date of Birth. L%1&, +*8, date&of birth# G%.)8

7& 16& '*%16F 7 /+ F /%7 +&/,#

"C# Your Mailing&Address. L%1&, +*8, ' / 0)0% 3 /77,&55 # G% . )8 7 & 16& 51, && 1 %/'& /%7 % 8 '9&,F!/5 4&))!/5 / % + -)**, * , /(/,1'&%1

%8'9&,F .01+F

51/1&F /%7!Z0(!.*7&# J?AL 4 0)) '/0) .*(0&5 *- 0%-*,'/10*%!,&)/1&7!1*!+*8, .)/0' 1*!+*8, /77,&55 16/1 +*8!&%1&, 6&,&#

You must inform DLSE&immediately of any change in&your mailing&address#

PART 3: Claim Filed Against (Employer Information)

"E# Employer/Business Name(s). L%1 & , 16& complete name *-

+*8, &'()*+& , /3/0%51 46*' +*8 /, & -0)0%3 16 & .)/0'F!1* 16& 9& 5 1 *-

+*8, :%*4)&73&# G- +*8, &'()*+&, 6/5 ' *,& 16/% *%& 9850%&55 %/'& S0%.)870%3!/ <7 *0%3!9850%&55 /5>!*, JV$ %/'&UF )051 /))

%/'&5 16/1 +*8!:%*4# If you are a garment worker or car wash worker, and your employer has closed its business and

opened up under a new name, list both&the&new name&(if you&know it) and&the&previous name&of your employer.

"W# Employer License Plate Number. L % 1 & , +*8, &'()*+&, ]5 2&60.)& license plate num

berF 0- + * 8 :%*4!1605 0%-*,'/10*%#

"X# Phone&Number of Employer. L%1&, 1 6 & telephone number *- +*8, &'()*+

&,F!with area codeF 0- +*8 :%*4 1605 0%-*,'/10* % #

"Y# Address of Employer/Business. L%1&, 16& last

known address *- +*8, & '()*+&,# ? 051 16& 51, & & 1 %/'&^!% 8 '9&,^!-)**,F 5801& *,

,**' %8 ' 9 &,!S0-!/%+ U^ .01+^ 51/1&^ /%7 Z0( .*7&# H605 /77 ,&55 '/+ 9& 70--&,&%1!-,*' 16 & /77,&55 46 &,& +*8 4*,:& 7 S460.6 +*8

56*8)7 )051 0% V*T "BU# If you are a garment worker or car wash worker, and your employer has changed its business address

50%.& +*8 4*,:&7 -*, 16& &'()*+&,F list both the new business address and the previous address,&0- +*8 :%*4 1605 0%-*,'/10*%#

"B# Address Where You Worked.

L%1&, 16& ad

dress where you performed workF 0- 70--&,& % 1 -,*' 16& /77 , & 55 +*8 )051 & 7 0% V*T!"Y#

?051 16&!51,&&1 %/'&^ % 8' 9&,^ -)**,F 5801&!*, ,**' %8 '9 &, S0- /%+U^ .01+^ 51/1&^ /%7 Z0( .*7&#

"[# Name of Person in Charge. L%1& , 16& first&and last&name of&the person in charge /1 16& )*./1 0* %

46& ,& +*8 4 * , :& 7 F!0- +*8 :% * 4

16& %/'&# H605 .*8)7 9& 16& *4%&,F!+*8 , 58(&,205 * ,F!/ '/%/3&,F!*, / % * 16 & , (&,5*% 46* ,/% 16& 9850%&5 5 *, *2& ,5 / 4 +*8, 4*,:#

"\# Job Title/Position of&Person in Charge.

L%1&, 1 6 & jo

b title *- 16& (& ,5 * % 0% .6/, 3 & F!0- :%*4%# L T /'()&O!<R)* * , _/%/ 3& , #>

Guide&to&Completing&“Initial&Report&or&Claim”&Form&(DLSE&Form&1)&

LABOR COMMISSIONER, STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT

CD# Type&of Business. L % 1& , 16& type of&business or industry 0% 460.6 + * 8 4*,:&7 -*, + * 8 , &'()*+ & ,#

C"# Type&of Work&Performed. L%1&, the type of&work you did for your employer.

CC# Total Number of Employees. L%1& , 16& /( ( ,* T 0'/1& 1* 1/ )!% 8 '9&, * - 4*,:&,5 &'()*+&7 9+ +*8, &'()*+&, F!0- +*8!:%*4#

CE# St

ill in Business? @6&. : <KLA> 0- +*8 : % * 4 16/1 + * 8 , &'()*+ & , 05 510))!*(& , /1 0% 3 015 985 0% & 55 #

CW# Description of Business Entity. @6&.: 16& 9*T 0%7 0./ 10% 3 46&16&, +*8 , &'()*+ & , 05 / .* ,( * , /1 0* % F!0% 7 02 07 8 / ))+ *4%&7 F!/

(/,1%&,

560(F / )0'01&7!)0/90)01+ .* '(/%+ S??@UF!*, )0'01&7 )0/ 9 0)01+ (/,1%&,560( S??= U F!0- +*8 :% * 4 1605 0% - * ,'/10*%#!

Part 4: Final Wages / Bounced Checks

CX# Date of Hire. L%1&, 16 & month, d

ay, and year that&you were hired 9+ +*8, & '()*+&,#

CY# Employment Status. G%7 0./ 1& 46&16&, +*8 still wo

rk -*, +* 8 , &'()* +& ,^!46&16& , +*8 quit +*8, ;*9 S0%. )8 7 & 16& 7/ 1& 16/1 + * 8

`801U^ 46&16&, +*8!4&,& discharged&S0%.)87& 16 & 7/1& 16/1!+* 8 4&,& 705.6/ ,3& 7U^ *,!46&16&,!/% *16 &,!5018 /10* % /(()0&5 S.6&.:

16& <*16&,> 9 *T /%7 9,0&-)+ 5( &.0-+ +*8,!5018/10*%!a -*, &T/ '()&F!<*% 705/90)01+ )&/2&>U#

Quit with 72&Hours Notice? G- + * 8 `801 4 016 BC 6* 8 , 5 %*10.&F!.6 & .: <KLA#>

9# Date of Final Paycheck. G- +* 8 `801F!.6&.: <KL A > 0- +*8 6/2& ,& .& 02 & 7 +*8, -0% / )!( / + .6 & . : 0%.)870% 3 /))!4/3& 5 *4&7F!/ % 7 16&%!

&%1&, 16

&!month, day, and year 16/1!+*8 ,&.&02&7 +* 8, -0%/) (/+.6& .:# b%7&, 16& )/4 F 0- +*8 `8 01 4016 BC 6*8,5 %*10.& S/%7

+*8 7* %*1 6/2& / 4,011&% .*%1,/.1 -*, / 7&-0%01& (&,0*7 *- &'( )*+'&% 1UF +*8, -0%/) (/+.6&.:!05 78& /1 16& 10'& *- `80110%3# G-

+*8!`801 without 3020%3 BC 6* 8 ,5 %*10.& S/%7 +* 8 7* %* 1 6/2& / 4,011&% .*%1,/ .1 -*, / 7&-0%01& ( & ,0* 7 *- &' ( )* + '&%1UF!+*8 ,

-0%/) (/+.6& .: 05 78& % * )/1&,!16/% BC 6*8,5 /-1& ,!`8 0110%3#

C[# Discharged?

G- +*8

4&,& 705.6/,3&7F!.6&. : <KLA> 0- +*8 6 / 2 & ,&.&02&7 +*8, -0%/) (/ +.6&.:!0%.)870%3!/)) 4/3&5 *4 &7F /% 7 16&%

&%1&, 16&!month, day, and year 16/1!+*8 ,&.&02&7 +* 8, -0%/) (/+.6&.:# b%7&, 16& )/4F 0- +*8 4&,& 705.6/,3&7F +*8 , -0%/)

(/+.6&.: 05 78& /%7!(/+/9)& 0'' &70/1&)+#

C\ /#

Method of Payment. @6&.: 16& 9* T 1* 0%70. / 1& 0- +*8 4&,& ( / 07 9+O!.6&. :F!. / 56 F!9 * 1 6 .6&.: /%7 ./ 56 F!*, *16& , '&16* 7 #

Paycheck&Could Not Be Cashed? @ 6 & . : <KLA> 0- +*8 4&,& ( /07 9+ .6 &. : and /%+ * - +*8, ( /+ . 6 & .: 5 .*8)7 %*1 9& ./56&7

9&./85& +*8, &' ()*+&, 6/5 %* /..*8%1 4016 16&!9/%: *, 0%58--0.0&%1 -8%75 0% 16&!/..*8%1 -,*' 460.6 16& .6 & .: 4/5 7 , /4%#

Part 5: Hours You Typically Worked

ED# Usually Worked the Same Hours? @6&.: 16& 9* T 0%70./10%3 46&16&, +*8 858/))+ 4*,:&7 16& 5/ '& 6*8 , 5 /%7 7 /+ 5 (&, 4 & & :F!* ,

0%51&/

7 46& 16 &, +*8, 4 * ,: 6*8,5 /%7P*, 7/+5 *- 4*,: 2/ ,0& 7 (&, 4& & : *, 4&,& 0,,&38)/,#! If your work hours or days of work

were irregular and you are claiming unpaid wages (for overtime&or nonDovertime&hours worked)&or meal and rest period

violations, submit the DLSE&Form 55 (filled out as best as you can, based on your best estimate of hours worked or any of

your own records that you kept of your hours worked).

E"# Your Typical Work&Hours.

R0))!*81 1

605 1/9)& Ic?K 0- +*8 3&%&,/))+ 4*,:&7 16& 5/ '& %8'9&, * - 6*8,5 (&, 4& & : # SG- +*8, 4 * ,:

6*8,5 4&,& 1**!0,,&38)/, 1*!&510'/1& / 1+(0./) 4*,:4&&:F JI cIH -0)) *81!1605 1/ 9)& F 9 8 1!-0)) *8 1!16& J?AL R* ,' XX 0%51&/7 #U! For

each&day&that you worked in your typical workweekF 302& +* 8 , best estimate * - 16& 10' & 5 16/1 +* 8 51/,1&7 /%7 51*((&7

4*,:0%3F /%7 16/1 +*8 1**: -*, /% 8%0%1&,,8(1&7 '&/) (&,0*7 *- /1 )&/51 ED '0%81&5 0% 460.6 +*8 4&,& ,&)0&2&7 *- /)) 781+#

• “DAY 1”&is the first day&of your

workweek, “DAY&2” is the second day&of your workweek, and so on. $ 4 *,:4&&: 05 /%+ B

.*%5&.8102& CWN6*8, (&,0*75F 51/,10%3 4016!16& 5/'& ./)&%7/, 7/+ &/.6!4&&:F 9&30%%0%3 /1 /%+ 6*8, *% /%+ 7/+F 5*!)*%3 /5 01

05 -0T&7 /%7 ,&38 )/ ,)+ ,&.8,,0%3#! G- + * 8 7* %* 1 :%*4 46/1 + * 8 , 4*,:4& & : 05 /%7 01 05 %* 1 &51/9)056 &7 9+ +* 8 , &'()*+ &, F!J ?A L

40)) 85& 16& ./)&%7/, 4&&: 51/,10%3 -,*' "COD" /#'# *% A8%7/+ 1* ' 07%0361 *% A/18,7/+F 4016 &/.6 4*,:7/+ &%70%3 /1

'07%0361^ 1685F <J$K " > * - +*8 , 4 *,:4 &&: 4 *8 )7 9& A8%7/+^ <J$K C> *- +*8, 4*,:4&&: 4*8)7!9& _ *%7/+F /%7!5* *%#

• Time&work&started&and&ended. R * , &/.6 7 / + 16/1 +* 8 4*,:&7 0% +* 8 , 1+(0./)!4*,:4&& :F!& % 1 &, 16& 10'& +*8 1+(0./))+ 9&3/%

/%7 &% 7&7 +*8, 7/+ *- 4 *,:F /%7 .6&.: 16&!.*,,&5(*%70%3!9*T -*, &016&, </' > * , <('#>

• 1st meal period&start and end&time. R* , &/.

6 7/+ 16/1 +* 8 4*,:&7 0% +*8 , 1+(0./)!4 * ,: 4&&:F!0- +* 8 1**: / % 8%0%1&,,8(1&7

'&/) (&,0*7 *- /1 )&/51 ED '0%81&5 0% 460.6 +*8 4&,& ,&)0&2&7 *- /)) 781+F &%1&, 16& 10'& +*8 1+(0./))+ 9&3/% /%7 &%7&7 +*8,

'&/) (&,0*7F /%7 .6&.: 16& .*,,&5(*%70%3 9*T -*, &016&, </'> *, <('#>

• 2nd meal period&start and end&time. R*, &/.

6 7/+ 16/1 +* 8 4*,:&7 0% +*8 , 1+(0./)!4 * ,: 4&&:F!0- +* 8 1**: / 5&.*%7

8%0%1&,,8(1&7!'&/) (&,0*7!*- /1 )&/51 ED '0%81&5 0%!460.6!+*8!4&,& ,&)0&2&7 *- /)) 781+F &%1&, 16& 10'& +*8 1+(0./))+!9&3/%

/%7 &%7&7 +*8, '&/) (&,0*7F /%7 .6&.: 16&!.*,,&5(*%70%3!9*T -*, &016&, </'> *, <('#>

• ONLY IF YOU WORKED A SPLIT SHIFT. R*, & / .

6 7/+ 16/1 +* 8 4*,:&7 0% +*8 , 1+(0./)!4 * ,: 4&&:F!&%1 &, 16& time your 1st&

shift ended S8%7&, <1st Shift ended&at>U /%7 .6&.:!16&!9*T!-*, &016&, </'>!*, <('#>! H6&% &%1&, 16&!time your 2nd shift&

began S8%7&, <2nd Shift started&at>U /%7 .6&.:!16&!9*T!-*, &016&, </'>!*, <('#>! LT/'()&O K *8, &' ()*+&, 5.6&78)&7 +* 8

1* 4*,: C 560-15 *% 16&!5/'&!4* ,:7/+F -,*' [ /' 1* "C ('F /%7 16&% -,*' X (' 1* \ ('# b%7&, < 1st Shift ended&at> &%1&,

<12 pm#> b%7 & , <2nd Shift started&at> &%1&, <5 pm#> If you did not work a split shift,&d o not fill&out these boxes.

Part 6: Payment of Wages

EC# Fixed Amount (“Salaried”

Employee)? @6&.: <KLA> 0- +*8 4 & ,& (/07 * , (,*'05& 7 / -0T&7 /'*8%1 *- 4/3&5 , & 3/ , 7 )& 55 *- 16&

%8'9&, *- 6*8,5 +*8!4*,:&7# H6&%!&%1&, 6*4 '8.6!'*%&+ +*8!4&,& actually&paidF /%7 6*4 - ,& ` 8 & % 1 )+ S58.6 /5 (&, 7/+ *,

&2&,+ C 4&&:5F &1.#U# G- +*8 4&,& (,*' 05&7 / 7 0--&,&%1 /'*8 %1F &%1&, 16/1 /' *8 %1F /%7 6*4 -,&`8&%1)+!+*8 4&,& 1* 9& (/07#

LABOR COMMISSIONER, STATE OF CALIFORNIA

DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT

Hourly&Pay? @6 & . : <KLA> 0- +*8 4&,& ( / 07 9+ 16& 6*8,# H6 & % &%1&, 6*4 ' 8.6 +*8 4&,& /.18/))+ (/07 (&, 6*8,# G- +*8 4&,&!

(,*'05&7!/ 70--&,&%1 6*8,)+ (/+ 16/%!+*8!,&.&02&7F /)5*!&%1&, 16/1 /'*8%1#

9# More than One Hourly Rate? @6&.: <KLA> 0- +*8 4&,& ( / 07 *, (,* '05&7 2/ , 0* 8 5 6*8,)+ ,/1&5F!9/5& 7 *% +* 8 , 6*8,5 4*,:&7 *,

70--&,&%1 ;*9!1/5:5F 16&% 9,0&-)+ 7&5.,09& +*8, 5018/10*%# LT/'()&O <=/07 d"D (&, 6*8, -*,!E D 6*8,5 8% )*/ 70% 3 1,8.:F /%7 d [

(&, 6*8, -*, "X 6*8,5 .6&.:0%3 0%2&%1*,+#>

EW# Paid by Piece&Rate? @6 &. : <KLA> 0- +*8 4&,& ( /07 9+ (0& .& ,/1&#

EX# Paid by Commission? @6&

.: <KLA> 0- +*8!,&.&02&7!.*''0550*%!(/+#

Part 7: Wages, Compensation & Penalties Owed

EY# Claim(s) and Amount(s). SNOTEO R*, .

)/0'5 '/,:&7 9+ eeeF!/ 11 /. 6 / 5&(/ ,/ 1 & .*'(8 1 /1 0* % -*,'# R* , 2/./10*% (/+F!-0))!*81 16&

<f/./10*% =/+!A.6&78)&>!-*,'^ -*, .*''0550*%!(/+F -0)) *81 16& J?AL R*,' "XX#U

• Check the&box for each claim you are&making, and fill in the&claim period and amount earned / claimed#

NOTE: Meal period wages# $% &' ( )*+ & , '/+ %*1 ,&`80,& /% + &'()*+& & 1* 4*,: 78,0%3 / %+ '&/)!(&,0* 7 '/%7/1& 7 9+

/% /(()0./9)&!*,7&, *- 16&!G%7851,0/) M &)-/,&!@*''0550*% SGM@U# G- /% &' ()*+&, -/0)5 1* (,*207&!/% &' ()*+&&!4016 /

'&/) (&,0*7 0% /..*,7/%.& 4016 /% /(()0./9)& *,7&, *- 16& GM @ F!/ %*%N&T&'(1 &'()*+&&!'/+ 5&&: *%&!/77010*%/) 6 *8,

*- (/+ /1 16& &'()*+&&]5 ,&38)/, ,/1& *- .*'(&%5/10*%!-*, &/.6!4*,:7/+ 16/1 16& '&/) (&,0*7!05 %*1 (,*207&7# b%7&,

'*51 GM@ *,7&,5F /% &'()*+&, '/+ %*1 &'()*+ /%+ (&,5*% -*, / 4*,: (&,0*7 *- '*,&!16/% -02&!SXU 6*8,5 4016*81 /

'&/) (&,0*7 *- %*1 )&55 16/% ED '0%81&5F *, -*, / 4*,: (&,0*7 *- '*,& 16/% 1&% S"DU 6*8,5 4016*81 (,*2070%3 / 5&.*%7

'&/) (&,0*7 *- %*1 )&55 16/% ED '0%81&5F 589;&.1 1* .&,1/0% 4/02&,5 9+ '818/) .*%5&%1 *, *16&, &T.&(10*%5# H6&

&'()*+&&!'851 9&!,&)0&2&7 *- /)) 781+ 78,0%3!16&!EDN'0%81& '&/) (&,0*7# Check the&IWC&order that applies to you. c*

'/11&, 6*4 '/%+ '&/) (&,0*75 /,& '055&7 0% *%& 4*,:7/+F *%)+ *%& '&/) (&,0*7 (,&'08'!05 0'(*5&7 -*, 16/1 7/+#

NOTE: Rest period wages# G% 3&%&,/ )F 16& GM@ * ,7&,5 ,&`80,& &'()*+&,5 1* /816*,0Z& /%7 (&,'01 %*%N &T&' (1

&'()*+&&5 1* 1/:&!,&51 (&,0*75F 460.6 0%5*-/, /5 (,/.10./9)&!56/)) 9&!0% 16&!'077)&!*- &/.6 4*,: (&,0*7# G- /% &'()*+&,

7*&5 %*1 (,*207& /%!&'()*+&& / ,&51 (&,0*7!0%!/..*,7/%.& 4016!/%!/(()0./9)& *,7&, *- 16& GM@F / %*%N&T&'(1

&'()*+&&!'/+ 5&&: *%&!/77010*%/) 6*8, *- (/+ /1 16& &'()*+&&]5 ,&38)/, ,/1& *- .*'(&%5/10*%!-*, &/.6!4*,:7/+ 16/1

16& ,&51!(&,0*7 05 %*1!(,*207&7# H6& / 816 *,0Z&7 ,&51!(&,0*7 10'& 56/)) 9& 9/5& 7 *% 16& 1*1/) 6 *8 ,5 4 * ,:&7 7/0)+ /1!16&

,/1& *-!1&% S"D U!' 0%8 1&5 %&1!,&51!10'& (&,!-*8 ,!SWU!6 * 8,5 *,!'/;*,!-,/.10*% 16&,&*-# R*, &T/'()&F 16&!1*1/) /'*8% 1 *-

,&51!(&,0*7 10'& ,&`80,&7 05 " D '0%81&5 0-!+*8 4*,: ' *,& 16/% 14* 6*8,5 /%7 8( 1* 50T 6*8,5^ CD '0%81&5 0-!+*8 4*,:

'*,& 16/% 50T 6*8,5 /%7 8( 1* "D 6*8,5^ ED '0%81&5 0- +*8 4*,: '*,& 16/%!"D 6*8,5 /%7!8( 1*!"W 6*8,5# Q* 4&2&,F!/

,&51!(&,0*7 7* &5 %*1!%&&7 1* 9& /816*,0Z& 7 -*,!&'()*+&&5 46*5& 1*1/ ) 7 /0)+ 4*,: 10'& 05 )&55 16/% 16 ,&& /%7 *%& N 6/)-

SE#XU!6*8,5# G% / 7 7 010* % F!.&,1/0% &'( )*+&&5 /,&!589;&.1 1* 5(&.0/) ,&51!(&,0*7 ,8)&5#! Check the&IWC&order that applies

to you. $816*,0Z&7!,&51 (&,0*7!10'& 05 .*8%1&7 / 5 6*8,5 4*,:&7 /%7 56 * 8)7 %*1 9& 7& 7 8 .1 & 7 -,*' 4/3&5# c* '/11&,

6*4 '/%+ ,&51 (&,0*75 /,& '055&7!0%!*%& 4*,:7/+F *%)+ *%& ,&51 (&,0*7!(,&'08' 05 0'(*5&7!-*, 16/1 7/+#

• Subtotal. $77!1*3&16&, /)) /'*8%15 &/,%&7P .)/0'&7F /%7!&%1&, 1605 5891*1/)#

• Total Amount Paid. G- +*8 , &

'()*+& , (/07 +* 8 /%+ .* '(&%5/1 0* % ,&)/10%3 1* +*8, .)/0'S5UF!& % 1& , 16& 1*1/ )!/'*8%1 (/07#

R*, /%+ 4/3&5 (/07F &%1&, 16&!3,*55 /'*8%1 (/07 1* +*8#

• Grand Total&Owed. R

,*' 16& Subtotal *- /'* 8%15 &/ ,% & 7 P .)/0'&7 F!subtract 16& Total Amount Paid#

EB# Penalties.

@6&.:

16& 9*TS&5U 0- +*8 /,&!/)5* .)/0'0%3O

• Waiting time penalties [Labor Code Section 203]# K*8 '/

+ 9& /9 )& 1* ,&.*2& , 4/010%3 10'& (&%/ )10&5 0- +*8 4&,&

705.6/,3&7!*, `801 /%7!+*8, &'()*+&, 40))-8))+ -/0)&7!1*!(/+ +*8, 4/3&5 &016&,O /1 16& 10'& +*8!4&,& 705.6/,3&7^ /1 16& 10'&

*- `80110%3 0- +*8!3/2& BC 6*8,5 %*10.&^ *, BC 6*8,5 /-1&, `80110%3 0- +*8!707!%*1 302& %*10.&# H6& 4/3&5 *- 16& &' ()*+&&

.*%10%8& /5 / (&%/)1+ -,*' 16&0, 78& 7/1& /1 16& 5/'& ,/1& 8%10) (/07!*, 8%10) /%!/.10*%!05 -0)&7!0%!.*8,1# =&%/)10&5 '/+

.*%10%8& -*, 8( 1* ED ./)&%7/, 7/+5!/%7 /,& .*'(8 1&7 9+!' 8)10()+0%3 16& &' ()*+&&]5!7/0)+!4/3& ,/1& 9+!16& %8'9&, *- 7/+5!

50%.& 16& (/+'&%1 *- 4/3 &5 9&./'& 78&#

• Penalties for “bounced” or dishonored checks [Labor Code&Section 203.1]# K*8 '/+ 9& /9)& 1* ,&.*2&, 58. 6 (&%/)10&5 0-

+*8 4&,& (/07 4016 / (/+.6 &.:!16/1 .*8)7 % *1 9& ./56&7 9+!+*8 9&./85& +*8, &'()*+&, 6/5 %* /..*8%1 4016!16& 9/%: *,

0%58--0.0&%1 -8%75 0% 16& / . .* 8 % 1 -,*' 460.6 16 & .6&.: 4/5 7,/ 4 %F!/% 7 +*8 /1 1& '(1&7 1* ./56 16/1 .6 & . : 40160% ED 7/+ 5 *-

,&.&020%3 01# K*8!'/+ 9& &%101)&7!1*!,&.*2&, / (&%/)1+ *- *%& 7/+]5 (/+ -*, &/.6!7/+ 16*5& 4/3&5 ,&'/0%!8%(/07!*, 8%10) /%!

/.10*% 05 .*'' &%.&7F 8( 1* ED ./)&%7/, 7/+5#

SIGN & DATE THE FORM.

SBPCD"CU