New York State Department of Labor, Division of Labor Standards Complaint Form (LS 223) Instructions
This form contains 377 fields organized into 101 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Another name known by at work | ||
| Another Name Known At Work | Text |
Provide any other name the person is known by at work.
|
| Authorization to Speak with Representative | ||
| Authorization to Speak with Representative Yes | Radiobutton |
Check this box if you want the form's recipient to speak with your representative about your claim.
|
| Authorization to Speak with Representative No | Radiobutton |
Check this box if you do not want the form's recipient to speak with your representative about your claim.
|
| Business Email | ||
| Business Email | Text |
Provide the email address of the business.
|
| Business Hours of Operation | ||
| Business Hours of Operation | Text |
Enter the business hours of operation, including days and times.
|
| Business Mailing address | ||
| Business Mailing Address Street | Text |
Enter the street number and street name for the business mailing address.
|
| Business Mailing Address Floor/Room/Suite Number | Text |
Enter the floor, room, or suite number for the business mailing address.
|
| Business Mailing Address City/Town | Text |
Enter the city or town of the business mailing address.
|
| Business Mailing Address County | Text |
Enter the county of the business mailing address.
|
| Business Mailing Address State | Text |
Enter the state of the business mailing address.
|
| Business Mailing Address Zip Code | Text |
Enter the five-digit zip code for the business mailing address.
|
| Business name | ||
| Business Name | Text |
Enter the operating name of the business.
|
| Business phone | ||
| Business Phone Area Code | Text |
Provide the three-digit area code for the business phone number.
|
| Business Phone Prefix | Text |
Provide the three-digit prefix for the business phone number.
|
| Business Phone Line Number | Text |
Provide the four-digit line number for the business phone number.
|
| Business Type | ||
| Restaurant | Checkbox |
Check this box if the business type is a restaurant.
|
| Retail Store | Checkbox |
Check this box if the business type is a retail store.
|
| Domestic Help | Checkbox |
Check this box if the business type involves domestic help services.
|
| Construction | Checkbox |
Check this box if the business type is construction.
|
| Office | Checkbox |
Check this box if the business type is an office.
|
| Other | Checkbox |
Check this box if the business type is not listed among the other options provided.
|
| Other Business Type | Text |
Provide the business type if it is not listed in the provided options.
|
| Call-in or Uniform Maintenance Pay | ||
| Call-in or Uniform Maintenance Pay - Yes | Radiobutton |
Check this box if you are owed call-in pay or uniform maintenance pay.
|
| Call-in or Uniform Maintenance Pay - No | Radiobutton |
Check this box if you are not owed call-in pay or uniform maintenance pay.
|
| Call-in or Uniform Maintenance Pay Explanation and Dates | Text |
Provide a detailed explanation and relevant dates if you are owed call-in pay or uniform maintenance pay.
|
| Claim Date Range | ||
| Claim Start Month | Text |
Enter the starting month for the claim date range.
|
| Claim Start Day | Text |
Enter the starting day for the claim date range.
|
| Claim Start Year | Text |
Enter the starting year for the claim date range.
|
| Claim End Month | Text |
Enter the ending month for the claim date range.
|
| Claim End Day | Text |
Enter the ending day for the claim date range.
|
| Claim End Year | Text |
Enter the ending year for the claim date range.
|
| Company Status | ||
| Still in Business Yes | Radiobutton |
Check this box if the company is currently operational.
|
| Still in Business No | Radiobutton |
Check this box if the company is no longer operational.
|
| Company Closure Date | Date |
Enter the date when the business closed.
|
| Complainant Mailing Address | ||
| Complainant Street Address | Text |
Enter the street number and name of the complainant's mailing address.
|
| Complainant Apartment Number | Text |
Enter the apartment, unit, or suite number of the complainant's mailing address, if applicable.
|
| Complainant City/Town | Text |
Enter the city or town of the complainant's mailing address.
|
| Complainant County | Text |
Enter the county of the complainant's mailing address.
|
| Complainant State | Text |
Enter the state of the complainant's mailing address.
|
| Complainant Zip Code | Text |
Enter the five or nine-digit zip code of the complainant's mailing address.
|
| Complainant Name | ||
| Complainant First Name | Text |
Enter the complainant's first name.
|
| Complainant Middle Name | Text |
Enter the complainant's middle name.
|
| Complainant Last Name | Text |
Enter the complainant's last name.
|
| Complainant Other phone | ||
| Complainant Other Phone Area Code | Text |
Enter the three-digit area code of the complainant's other phone number.
|
| Complainant Other Phone Prefix | Text |
Enter the three-digit prefix of the complainant's other phone number.
|
| Complainant Other Phone Line Number | Text |
Enter the four-digit line number of the complainant's other phone number.
|
| Complainant Phone | ||
| Complainant Phone Area Code | Text |
Provide the three-digit area code of the complainant's phone number.
|
| Complainant Phone Exchange | Text |
Provide the three-digit exchange of the complainant's phone number.
|
| Complainant Phone Line Number | Text |
Provide the four-digit line number of the complainant's phone number.
|
| Date | ||
| Date Month | Date |
Enter the month of the date.
|
| Date Day | Date |
Enter the day of the date.
|
| Date Year | Date |
Enter the year of the date.
|
| Day of Rest Complaint | ||
| Day of Rest | Checkbox |
Check this box if the employer failed to provide a day of rest.
|
| Day of Rest Complaint Explanation | Text |
Provide details if the employer failed to provide a day of rest.
|
| Dishonored Paycheck Information | ||
| Dishonored Check Number | Text |
Provide the check number if your paycheck was not honored by the bank.
|
| Text |
Please enter your email address.
|
|
| Employer Bank Name and Location | ||
| Bank Name and Location | Text |
Enter the employer's bank name and location.
|
| Employer Bankruptcy Status | ||
| Yes | Radiobutton |
Check this box if the employer has filed for bankruptcy.
|
| No | Radiobutton |
Check this box if the employer has not filed for bankruptcy.
|
| Unknown | Radiobutton |
Check this box if you do not know whether the employer has filed for bankruptcy.
|
| Employer Tip Handling Information | ||
| Kept Tips - No | Checkbox |
Check this box if your employer has not kept your or any other employee's tips.
|
| Kept Tips - Yes - Yours | Checkbox |
Check this box if your employer has kept your tips.
|
| Kept Tips - Yes - Others' | Checkbox |
Check this box if your employer has kept other employees' tips.
|
| Employer Tip Handling Explanation | Text |
Please provide a detailed explanation regarding the amount of tips received or how tips were handled by the employer.
|
| Explanation for Unpaid Wages | ||
| Explanation for Unpaid Wages | Text |
Provide a detailed explanation if you answered 'No' to any of the questions regarding minimum wage, overtime, or extra pay for specific work conditions.
|
| Explanation of Promised Benefits | ||
| Explanation of Promised Benefits | Text |
Provide a detailed explanation of the benefits that were promised, or indicate that a copy of the written policy/handbook is attached.
|
| Extra Hour Pay Status | ||
| 35e Extra Hour Pay Status - Yes | Radiobutton |
Check this box if you are paid an extra hour for working 2 shifts in one day or for working more than 10 hours in one day.
|
| 35e Extra Hour Pay Status - No | Radiobutton |
Check this box if you are not paid an extra hour for working 2 shifts in one day or for working more than 10 hours in one day.
|
| Fifth Unpaid Wages Claim Row | ||
| Fifth Payroll Week Ending Date | Date |
Enter the ending date for the fifth payroll week being claimed.
|
| Fifth Number of Days Worked in the Week | Text |
Enter the number of days worked during the fifth payroll week.
|
| Fifth Hours Worked in the Week | Text |
Enter the total number of hours worked during the fifth payroll week.
|
| Fifth Rate of Pay | Number |
Enter the earned or promised rate of pay for the fifth payroll week.
|
| Fifth Illegal Deductions from Wages | Number |
Enter the amount of any illegal deductions from wages for the fifth payroll week.
|
| Fifth Gross Wages Owed | Number |
Enter the total gross wages owed for the fifth payroll week.
|
| Fifth Gross Wages Paid | Number |
Enter the amount of gross wages the employer has already paid for the fifth payroll week.
|
| Fifth Difference Between Gross Wages Owed and Paid | Number |
Enter the difference between the gross wages owed and the gross wages paid for the fifth payroll week.
|
| First Paid Sick Leave Record | ||
| First Time Period Paid Sick Leave Accrued | Text |
Enter the start and end dates for the time period during which the first paid sick leave was accrued.
|
| First Amount of Paid Sick Leave Accrued | Number |
Enter the total number of hours for the first paid sick leave accrued.
|
| First Date(s) Paid Sick Leave Used | Date |
Enter the date or dates when the first paid sick leave was used.
|
| First Amount of Benefit Time Owed | Number |
Enter the total number of benefit time hours owed for the first record.
|
| First Regular Rate of Pay | Number |
Enter the regular hourly rate of pay for the first record.
|
| First Amount of Benefit Payment Due | Number |
Enter the total amount of benefit payment due for the first record.
|
| First Rate of Pay Information | ||
| First Rate Pay Start Date Month | Text |
Enter the month for the start date of the first rate of pay.
|
| First Rate Pay Start Date Day | Text |
Enter the day for the start date of the first rate of pay.
|
| First Rate Pay Start Date Year | Text |
Enter the year for the start date of the first rate of pay.
|
| First Regular Pay Rate | Number |
Enter the dollar amount for the first regular pay rate.
|
| First Regular Pay Rate Unit | Text |
Enter the unit of time (e.g., hour, day, week) for the first regular pay rate.
|
| First Rate Pay End Date Month | Text |
Enter the month for the end date of the first rate of pay.
|
| First Rate Pay End Date Day | Text |
Enter the day for the end date of the first rate of pay.
|
| First Rate Pay End Date Year | Text |
Enter the year for the end date of the first rate of pay.
|
| First Overtime Pay Rate | Number |
Enter the dollar amount for the first overtime pay rate.
|
| First Overtime Pay Rate Unit | Text |
Enter the unit of time (e.g., hour, day, week) for the first overtime pay rate.
|
| First Unpaid Wages Claim Row | ||
| First Payroll Week Ending Date | Date |
Enter the ending date for the first payroll week.
|
| First Number of Days Worked | Text |
Enter the number of days worked during the first payroll week.
|
| First Hours Worked | Text |
Enter the total hours worked during the first payroll week.
|
| First Rate of Pay | Number |
Enter the rate of pay earned or promised for the first payroll week.
|
| First Illegal Deductions | Number |
Enter the amount of any illegal deductions from wages for the first payroll week, such as fines or breakage costs.
|
| First Gross Wages Owed | Number |
Enter the total gross wages owed for the first payroll week.
|
| First Gross Wages Paid | Number |
Enter the amount of gross wages already paid by the employer for the first payroll week.
|
| First Wages Difference | Number |
Enter the difference between the gross wages owed and the gross wages paid for the first payroll week.
|
| First Wage Supplement Record | ||
| First Record Type of Benefit Owed | Text |
Enter the type of wage supplement benefit that is owed.
|
| First Record Time Period Benefit Earned | Text |
Enter the time period during which the wage supplement benefit was earned.
|
| First Record Date Benefit Payment Due | Date |
Enter the date when the wage supplement benefit payment was due.
|
| First Record Amount of Benefit Time Owed | Text |
Enter the amount of benefit time that is owed.
|
| First Record Amount of Benefit Payment Due | Number |
Enter the monetary amount of the benefit payment that is due.
|
| First Record Written Policy | Checkbox |
Check this box if the first wage supplement benefit was promised by a written policy.
|
| First Record Verbal Promise | Checkbox |
Check this box if the first wage supplement benefit was promised by a verbal agreement.
|
| Form Assistance Inquiry | ||
| Form Assistance Inquiry - Did Anyone Help Yes | Radiobutton |
Check this box if someone other than the representative helped you fill out this form.
|
| Form Assistance Inquiry - Did Anyone Help No | Radiobutton |
Check this box if no one other than the representative helped you fill out this form.
|
| Assistance Details | Text |
Provide details about who helped you with the form and why they provided assistance.
|
| Fourth Unpaid Wages Claim Row | ||
| Fourth Payroll Week Ending Date | Date |
Enter the ending date of the fourth payroll week for which wages are claimed.
|
| Fourth Number of Days Worked | Text |
Enter the number of days worked during the fourth payroll week.
|
| Fourth Hours Worked | Text |
Enter the total hours worked during the fourth payroll week.
|
| Fourth Rate of Pay | Text |
Enter the earned or promised rate of pay for the fourth payroll week, including units (e.g., per hour, per week).
|
| Fourth Illegal Deductions | Number |
Enter any illegal deductions made from wages during the fourth payroll week.
|
| Fourth Gross Wages Owed | Number |
Enter the total gross wages owed for the fourth payroll week.
|
| Fourth Gross Wages Paid | Number |
Enter the amount of gross wages paid by the employer for the fourth payroll week.
|
| Fourth Wages Difference | Number |
Enter the difference between gross wages owed and gross wages paid for the fourth payroll week.
|
| Friday Workday Details | ||
| Friday Workday Started Hour | Text |
Enter the hour when your workday started on Friday.
|
| Friday Workday Started Minute | Text |
Enter the minute when your workday started on Friday.
|
| Friday Workday Started AM PM | Text |
Enter "AM" or "PM" for when your workday started on Friday.
|
| Friday Workday Ended Hour | Text |
Enter the hour when your workday ended on Friday.
|
| Friday Workday Ended Minute | Text |
Enter the minute when your workday ended on Friday.
|
| Friday Workday Ended AM PM | Text |
Enter "AM" or "PM" for when your workday ended on Friday.
|
| Friday Time Off for Meals | Text |
Enter the total time taken off for meals on Friday.
|
| Friday Total Hours | Number |
Enter the total number of hours worked on Friday.
|
| Hire Date | ||
| Hire Date Month | Date |
Enter the month the individual was hired.
|
| Hire Date Day | Date |
Enter the day the individual was hired.
|
| Hire Date Year | Date |
Enter the year the individual was hired.
|
| Hiring Manager Name and Title | ||
| Hiring Manager Name and Title | Text |
Provide the name and title of the person who hired you.
|
| Job Title | ||
| Your job title | Text |
Please provide your job title.
|
| Last Day Worked and Reason for Leaving | ||
| Last Day Worked Day | Text |
Enter the day of the last day you worked.
|
| Last Day Worked Month | Text |
Enter the month of the last day you worked.
|
| Last Day Worked Year | Text |
Enter the year of the last day you worked.
|
| Reason for Leaving | Text |
Provide the reason for leaving your last job.
|
| LCM | ||
| LCM | Text |
Enter the Labor Case Management (LCM) identifier.
|
| Legal entity type | ||
| Individual | CheckBox | |
| LLC | Checkbox |
Check this box if the legal entity type is a Limited Liability Company (LLC).
|
| Partnership | Checkbox |
Check this box if the legal entity type is a partnership.
|
| Corporation | Checkbox |
Check this box if the legal entity type is a corporation.
|
| Other | Checkbox |
Check this box if the legal entity type is not an individual, LLC, partnership, or corporation.
|
| Other Legal Entity Type | Text |
Specify the legal entity type of the business if it is not Individual, LLC, Partnership, or Corporation.
|
| Legal name (if different) | ||
| Legal Name (if different) | Text |
Enter the legal name of the business if it is different from the primary business name.
|
| LS ID | ||
| LS ID | Number |
Provide the Labor Standards Identification number.
|
| Mailing Address | ||
| Mailing Street Address | Text |
Enter the street number and street name for the mailing address.
|
| Apartment or Unit Number | Text |
Enter the apartment, suite, or unit number for the mailing address, if applicable.
|
| City/Town | Text |
Enter the city or town for the mailing address.
|
| County | Text |
Enter the county for the mailing address.
|
| State | Text |
Enter the state for the mailing address, typically as a two-letter abbreviation.
|
| Zip Code | Text |
Enter the zip code for the mailing address.
|
| Manager/Supervisor/Foreman Name | ||
| Manager/Supervisor/Foreman Name | Text |
Enter the full name of your manager, supervisor, or foreman.
|
| Meal Period Complaint | ||
| Meal Period Complaint: Failed to Provide 30-Minute Meal Period | Checkbox |
Check this box if the employer failed to provide you with a 30-minute meal period.
|
| 30-Minute Meal Period Explanation | Text |
Provide an explanation if the employer failed to provide a 30-minute meal period.
|
| Meal Period Complaint: Paid for Time Worked: Yes | Radiobutton |
Check this box if you were paid for the time worked when the employer failed to provide your meal period.
|
| Meal Period Complaint: Paid for Time Worked: No | Radiobutton |
Check this box if you were not paid for the time worked when the employer failed to provide your meal period.
|
| Minimum Wage Payment Status | ||
| Minimum Wage Paid - Yes | Radiobutton |
Check this box if you are paid the minimum wage for each hour worked.
|
| Minimum Wage Paid - No | Radiobutton |
Check this box if you are not paid the minimum wage for each hour worked.
|
| Minor Employment Rules Complaint | ||
| 37g. Follow rules for employment of minors (under 18) | Checkbox |
Check this box if the employer failed to follow rules for the employment of minors (under 18).
|
| 37g. Minor Employment Rules Explanation | Text |
Provide details explaining how the employer failed to follow rules for the employment of minors under 18.
|
| Monday Workday Details | ||
| Monday Start Hour | Text |
Enter the hour your workday started on Monday.
|
| Monday Start Minute | Text |
Enter the minute your workday started on Monday.
|
| Monday Start AM/PM | Text |
Enter 'AM' or 'PM' to indicate whether your workday started in the morning or afternoon on Monday.
|
| Monday End Hour | Text |
Enter the hour your workday ended on Monday.
|
| Monday End Minute | Text |
Enter the minute your workday ended on Monday.
|
| Monday End AM/PM | Text |
Enter 'AM' or 'PM' to indicate whether your workday ended in the morning or afternoon on Monday.
|
| Monday Time Off for Meals | Text |
Enter the total time taken off for meals on Monday, including units like 'min' or 'hours'.
|
| Monday Total Hours | Number |
Enter the total number of hours worked on Monday.
|
| Name of Person Who Paid Wages | ||
| Name of Person Who Paid Wages | Text |
Provide the full name of the person who paid your wages.
|
| Notices/Poster Complaint | ||
| Post required notices/Minimum Wage Poster | Checkbox |
Check this box if the employer failed to post required notices or the Minimum Wage Poster.
|
| Notices/Poster Complaint Details | Text |
Provide additional details regarding the employer's failure to post required notices or the Minimum Wage Poster.
|
| Other Non-Wage Complaint | ||
| Other Non-Wage Complaint | Checkbox |
Check this box if your non-wage complaint against the employer is for a reason not specified in options 37a through 37g.
|
| Other Non-Wage Complaint Details | Text |
Provide details for any other non-wage related complaint not listed above.
|
| Out-of-State Work Status | ||
| Yes | Radiobutton |
Check this box if you regularly traveled outside New York State for work.
|
| No | Radiobutton |
Check this box if you did not regularly travel outside New York State for work.
|
| Overtime Pay Status (Over 40 Hours) | ||
| 35b. Yes, Paid Time and a Half | Radiobutton |
Check this box if you are paid time and a half for the hours worked over 40.
|
| 35b. No, Not Paid Time and a Half | Radiobutton |
Check this box if you are not paid time and a half for the hours worked over 40.
|
| Overtime Rate of Pay | ||
| Overtime Rate of Pay | Number |
Please enter your overtime rate of pay.
|
| Owner Email | ||
| Owner Email | Text |
Enter the email address of the owner.
|
| Owner Name and Title | ||
| 9a. Owner Name and Title | Text |
Please provide the full name(s) and title(s) of the owner(s).
|
| Owner Phone Number | ||
| Owner Phone Number - Area Code | Text |
Enter the three-digit area code for the owner's phone number.
|
| Owner Phone Number - Prefix | Text |
Enter the three-digit prefix of the owner's phone number.
|
| Owner Phone Number - Line Number | Text |
Enter the four-digit line number of the owner's phone number.
|
| Page 7 | ||
| Additional Comments and Information | Text |
Provide any additional comments or useful information regarding this claim.
|
| Date (Month) | Text |
Enter the two-digit month for the date of signature.
|
| Date (Day) | Text |
Enter the two-digit day for the date of signature.
|
| Date (Year) | Text |
Enter the four-digit year for the date of signature.
|
| Paid Sick Leave Complaint | ||
| Provide for Accrual of NYS Paid Sick Leave | Checkbox |
Check this box if the employer failed to provide for the accrual of required New York State Paid Sick Leave.
|
| Paid Sick Leave Accrual Complaint | Text |
Please explain the complaint regarding the employer's failure to provide for the accrual of required New York State Paid Sick Leave.
|
| Paid Sick Leave Totals | ||
| Total Regular Rate of Pay | Number |
Enter the total regular rate of pay for the paid sick leave.
|
| Total Benefit Payment Due | Number |
Enter the total amount of benefit payment due for the paid sick leave.
|
| Pay Rate Notice Complaint | ||
| Provide Notice of Pay Rate | Checkbox |
Check this box if the employer failed to provide a notice of pay rate with all required information.
|
| 37d. Pay Rate Notice Complaint Details | Text |
Describe how the employer failed to provide a notice of pay rate with all required information.
|
| Payday and Period Covered | ||
| Monday | Radiobutton |
Check this box if your payday was Monday.
|
| Tuesday | Radiobutton |
Check this box if your payday was Tuesday.
|
| Wednesday | Radiobutton |
Check this box if your payday was Wednesday.
|
| Thursday | Radiobutton |
Check this box if your payday was Thursday.
|
| Friday | Radiobutton |
Check this box if your payday was Friday.
|
| Saturday | Radiobutton |
Check this box if your payday was Saturday.
|
| Sunday | Radiobutton |
Check this box if your payday was Sunday.
|
| Period Covered | Text |
Enter the period covered by the payment, such as a day of the week (e.g., Fri for Sat through Fri).
|
| Payment Frequency | ||
| Daily | Checkbox |
Check this box if you were paid daily.
|
| Weekly | Checkbox |
Check this box if you were paid weekly.
|
| Every two weeks | Checkbox |
Check this box if you were paid every two weeks.
|
| Other | Checkbox |
Check this box if you were paid on a frequency other than daily, weekly, or every two weeks.
|
| Other Payment Frequency | Text |
Enter the frequency of payment if it is not Daily, Weekly, or Every two weeks.
|
| Previous Legal Action Inquiry | ||
| Previous Legal Action Inquiry - Yes | Radiobutton |
Check this box if you have already taken action, such as filing in small claims court or a lawsuit, to recover your wages.
|
| Previous Legal Action Inquiry - No | Radiobutton |
Check this box if you have not yet taken any action, such as filing in small claims court or a lawsuit, to recover your wages.
|
| Previous Legal Action Explanation | Text |
Provide a detailed explanation of any previous legal action taken to recover your wages, such as filing in small claims court or a lawsuit.
|
| Primary/preferred language | ||
| Primary/preferred language | Text |
Enter your primary or preferred language.
|
| PV and Priority | ||
| PV | Text |
Enter the PV value.
|
| Priority | Text |
Enter the priority level.
|
| Rate of Pay | ||
| Rate of Pay | Number |
Please provide your regular rate of pay.
|
| Day | Radiobutton |
Check this box if your rate of pay is calculated per day.
|
| Week | Radiobutton |
Check this box if your rate of pay is calculated per week.
|
| Hour | Radiobutton |
Check this box if your rate of pay is calculated per hour.
|
| Other | Radiobutton |
Check this box if your rate of pay is based on a period other than daily, weekly, or hourly, and specify the period.
|
| Other Rate of Pay Period | Text |
Please specify the 'other' period for your rate of pay, if it is not daily, weekly, or hourly.
|
| Regular Tip Earnings Information | ||
| Regular Tip Earnings: Yes | Radiobutton |
Check this box if you regularly earned tips.
|
| Regular Tip Earnings: No | Radiobutton |
Check this box if you did not regularly earn tips.
|
| Average Tips Per Hour | Number |
Enter the average amount of tips earned per hour.
|
| Relationship with Business | ||
| Still employed | Checkbox |
Check this box if you are still employed by the business mentioned.
|
| Discharged | Checkbox |
Check this box if your employment with the business was terminated by the employer.
|
| Quit | Checkbox |
Check this box if you voluntarily left your employment with the business.
|
| Temporarily laid-off | Checkbox |
Check this box if your employment with the business was temporarily suspended due to a lay-off.
|
| Representative Assistance Inquiry | ||
| Representative Assisted in Filing Claim: Yes | Radiobutton |
Check this box if the representative has assisted you in filing this claim.
|
| Representative Assisted in Filing Claim: No | Radiobutton |
Check this box if the representative has not assisted you in filing this claim.
|
| Representative Inquiry | ||
| Representative Inquiry: Yes | Radiobutton |
Check this box if you have a representative (e.g., private attorney, advocacy group) for this claim.
|
| Representative Inquiry: No | Radiobutton |
Check this box if you do not have a representative for this claim.
|
| Representative Name | Text |
Enter the name of the person or group acting as your representative.
|
| Representative Payment Inquiry | ||
| Paid Representative Yes | Radiobutton |
Check this box if you have paid or plan to pay the representative.
|
| Paid Representative No | Radiobutton |
Check this box if you have not paid and do not plan to pay the representative.
|
| Saturday Workday Details | ||
| Saturday Start Time Hour | Text |
Enter the hour for when the workday started on Saturday.
|
| Saturday Start Time Minute | Text |
Enter the minute for when the workday started on Saturday.
|
| Saturday Start Time AM/PM | Text |
Enter 'AM' or 'PM' to indicate the part of the day the workday started on Saturday.
|
| Saturday End Time Hour | Text |
Enter the hour for when the workday ended on Saturday.
|
| Saturday End Time Minute | Text |
Enter the minute for when the workday ended on Saturday.
|
| Saturday End Time AM/PM | Text |
Enter 'AM' or 'PM' to indicate the part of the day the workday ended on Saturday.
|
| Saturday Time Off for Meals | Text |
Enter the total time taken off for meals on Saturday, including units (e.g., '30 min' or '1 hour').
|
| Saturday Total Hours | Number |
Enter the total number of hours worked on Saturday.
|
| Second Paid Sick Leave Record | ||
| Second Time Period Paid Sick Leave Accrued | Text |
Enter the second time period during which paid sick leave was accrued.
|
| Second Amount of Paid Sick Leave Accrued | Number |
Enter the second total amount of paid sick leave accrued in hours.
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| Second Date(s) Paid Sick Leave Used | Date |
Enter the second date or dates when the paid sick leave was used.
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| Second Amount of Benefit Time Owed | Number |
Enter the second amount of benefit time owed in hours.
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| Second Regular Rate of Pay | Number |
Enter the second regular rate of pay per hour.
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| Second Amount of Benefit Payment Due | Number |
Enter the second total amount of benefit payment due.
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| Second Rate of Pay Information | ||
| Second Rate From Month | Text |
Enter the month the second rate of pay period starts.
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| Second Rate From Day | Text |
Enter the day the second rate of pay period starts.
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| Second Rate From Year | Text |
Enter the year the second rate of pay period starts.
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| Second Regular Pay Amount | Number |
Enter the dollar amount for your second regular rate of pay.
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| Second Regular Pay Period | Text |
Enter the period for your second regular rate of pay (e.g., hour, week, month).
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| Second Rate To Month | Text |
Enter the month the second rate of pay period ends.
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| Second Rate To Day | Text |
Enter the day the second rate of pay period ends.
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| Second Rate To Year | Text |
Enter the year the second rate of pay period ends.
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| Second Overtime Pay Amount | Number |
Enter the dollar amount for your second overtime rate of pay.
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| Second Overtime Pay Period | Text |
Enter the period for your second overtime rate of pay (e.g., hour, week, month).
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| Second Unpaid Wages Claim Row | ||
| Second Payroll Week Ending Date | Date |
Enter the ending date for the second payroll week in which unpaid wages are being claimed.
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| Second Number of Days Worked | Text |
Enter the number of days worked during the second week for which unpaid wages are being claimed.
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| Second Hours Worked | Number |
Enter the total hours worked during the second week for which unpaid wages are being claimed.
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| Second Rate of Pay | Number |
Enter the earned or promised rate of pay for the second week in which unpaid wages are being claimed.
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| Second Illegal Deductions | Number |
Enter the total amount of any illegal deductions from wages for the second week.
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| Second Gross Wages Owed | Number |
Enter the total gross wages owed for the second week.
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| Second Gross Wages Paid | Number |
Enter the amount of gross wages already paid by the employer for the second week.
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| Second Wages Difference | Number |
Enter the difference between the gross wages owed and the gross wages paid for the second week.
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| Second Wage Supplement Record | ||
| Second Type of Benefit Owed | Text |
Specify the type of wage benefit owed for the second record.
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| Second Time Period Benefit Earned | Text |
Enter the time period during which the benefit for the second record was earned.
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| Second Date Benefit Payment Due | Date |
Enter the date when the benefit payment for the second record was due.
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| Second Amount of Benefit Time Owed | Text |
Specify the amount of benefit time owed for the second record.
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| Second Amount of Benefit Payment Due | Number |
Enter the monetary amount of the benefit payment due for the second record.
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| Second Record Written Policy | Checkbox |
Check this box if the second wage supplement benefit was promised by a written policy.
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| Second Record Verbal Promise | Checkbox |
Check this box if the second wage supplement benefit was promised by a verbal promise.
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| Sunday Workday Details | ||
| Sunday Workday Start Hour | Text |
Enter the hour when the workday started on Sunday.
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| Sunday Workday Start Minute | Text |
Enter the minute when the workday started on Sunday.
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| Sunday Workday Start AM/PM | Text |
Enter whether the workday started in AM or PM on Sunday.
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| Sunday Workday End Hour | Text |
Enter the hour when the workday ended on Sunday.
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| Sunday Workday End Minute | Text |
Enter the minute when the workday ended on Sunday.
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| Sunday Workday End AM/PM | Text |
Enter whether the workday ended in AM or PM on Sunday.
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| Sunday Time Off for Meals | Text |
Enter the duration of time taken off for meals on Sunday.
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| Sunday Total Hours | Number |
Enter the total number of hours worked on Sunday.
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| Taken By | ||
| Taken By Person | Text |
Enter the name or identifier of the person who took the complaint.
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| Third Paid Sick Leave Record | ||
| Third Paid Sick Leave Accrual Period | Text |
Enter the time period during which this third record of paid sick leave was accrued.
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| Third Paid Sick Leave Accrued Amount | Number |
Enter the amount of paid sick leave accrued for this third record.
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| Third Paid Sick Leave Used Date(s) | Date |
Enter the date or dates when this third record of paid sick leave was used.
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| Third Benefit Time Owed Amount | Number |
Enter the amount of benefit time owed for this third record.
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| Third Regular Pay Rate | Number |
Enter the regular rate of pay for this third record.
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| Third Benefit Payment Due Amount | Number |
Enter the amount of benefit payment due for this third record.
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| Third Rate of Pay Information | ||
| Third Rate Start Month | Text |
Enter the month for the start date of the third rate of pay information.
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| Third Rate Start Day | Text |
Enter the day for the start date of the third rate of pay information.
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| Third Rate Start Year | Text |
Enter the year for the start date of the third rate of pay information.
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| Third Regular Pay Rate | Number |
Enter the regular pay rate amount for the third rate of pay information.
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| Third Regular Pay Unit | Text |
Enter the unit for the regular pay rate for the third rate of pay information.
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| Third Rate End Month | Text |
Enter the month for the end date of the third rate of pay information.
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| Third Rate End Day | Text |
Enter the day for the end date of the third rate of pay information.
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| Third Rate End Year | Text |
Enter the year for the end date of the third rate of pay information.
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| Third Overtime Pay Rate | Number |
Enter the overtime pay rate amount for the third rate of pay information.
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| Third Overtime Pay Unit | Text |
Enter the unit for the overtime pay rate for the third rate of pay information.
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| Third Unpaid Wages Claim Row | ||
| Payroll week ending date - row 3 | Text | |
| Number of days worked in the week - row 3 | Text | |
| Hours worked in the week - row 3 | Text | |
| Rate of pay (earned or promised) row 3 | Text | |
| E Illegal Deductio ns from Wages eg fines breakage etc - row 3 | Text | |
| Gross wages owed for the week - row 3 | Text | |
| Gross wages paid (if employer paid some of the wages owed write the amount here - row 3 | Text | |
| Difference between gross wages owed and gross wages paid - row 3 | Text | |
| Third Wage Supplement Record | ||
| Third Type of Benefit Owed | Text |
Enter the type of benefit owed for the third wage supplement record.
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| Third Time Period Benefit Earned | Text |
Provide the time period during which the benefit was earned for the third wage supplement record.
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| Third Date Benefit Payment Due | Date |
Enter the date when the benefit payment was due for the third wage supplement record.
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| Third Amount of Benefit Time Owed | Text |
Specify the amount of benefit time owed for the third wage supplement record.
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| Third Amount of Benefit Payment Due | Number |
Enter the amount of the benefit payment that is due for the third wage supplement record.
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| Third Written Policy | Checkbox |
Check this box if the third wage supplement is promised by a written policy.
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| Third Verbal Promise | Checkbox |
Check this box if the third wage supplement is promised by a verbal agreement.
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| Thursday Workday Details | ||
| Thursday Workday Start Hour | Text |
Enter the hour the workday started on Thursday.
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| Thursday Workday Start Minute | Text |
Enter the minute the workday started on Thursday.
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| Thursday Workday Start AM/PM | Text |
Enter 'AM' or 'PM' for the workday start time on Thursday.
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| Thursday Workday End Hour | Text |
Enter the hour the workday ended on Thursday.
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| Thursday Workday End Minute | Text |
Enter the minute the workday ended on Thursday.
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| Thursday Workday End AM/PM | Text |
Enter 'AM' or 'PM' for the workday end time on Thursday.
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| Thursday Time off for Meals | Text |
Enter the total time taken off for meals on Thursday.
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| Thursday Total Hours | Number |
Enter the total number of hours worked on Thursday.
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| Total Number of Employees | ||
| Total Number of Employees | Number |
Enter the total number of employees.
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| Total Unpaid Wages | ||
| Total Unpaid Wages | Number |
Enter the total amount of unpaid wages claimed.
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| Total Wage Supplement Amount | ||
| Total Wage Supplement Amount | Number |
Enter the total amount of all wage supplement benefits due.
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| Tuesday Workday Details | ||
| Tuesday Start Hour | Text |
Enter the hour when work started on Tuesday.
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| Tuesday Start Minute | Text |
Enter the minute when work started on Tuesday.
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| Tuesday Start AM/PM | Text |
Enter 'AM' or 'PM' for the workday start time on Tuesday.
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| Tuesday End Hour | Text |
Enter the hour when work ended on Tuesday.
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| Tuesday End Minute | Text |
Enter the minute when work ended on Tuesday.
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| Tuesday End AM/PM | Text |
Enter 'AM' or 'PM' for the workday end time on Tuesday.
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| Tuesday Meal Time Off | Text |
Enter the duration of time taken off for meals on Tuesday, including units (e.g., '30 min').
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| Tuesday Total Hours | Number |
Enter the total number of hours worked on Tuesday.
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| Type of Work Performed | ||
| Type of Work Performed | Text |
Specify the type of work you performed.
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| Uniform Cost Information | ||
| 32c. Yes | Radiobutton |
Check this box if the uniforms were free of charge.
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| 32c. No | Radiobutton |
Check this box if the uniforms were not free of charge.
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| Uniform Cost | Number |
Enter the total cost of the uniforms.
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| Uniform Description | ||
| Uniform Description | Text |
Provide a detailed description of the uniform.
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| Uniform Requirement | ||
| Uniform Requirement - Yes | Radiobutton |
Check this box if you were required to wear a uniform.
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| Uniform Requirement - No | Radiobutton |
Check this box if you were not required to wear a uniform.
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| Union Membership Information | ||
| Union Member - Yes | Radiobutton |
Check this box if you were a member of a union.
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| Union Member - No | Radiobutton |
Check this box if you were not a member of a union.
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| Union Name and Local Number | Text |
Enter the name of your union and your local number.
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| Wage Claim Period | ||
| Date From Month | Text |
Enter the month when the wage claim period begins.
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| Date From Day | Text |
Enter the day of the month when the wage claim period begins.
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| Date From Year | Text |
Enter the year when the wage claim period begins.
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| Date To Month | Text |
Enter the month when the wage claim period ends.
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| Date To Day | Text |
Enter the day of the month when the wage claim period ends.
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| Date To Year | Text |
Enter the year when the wage claim period ends.
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| Wage Payment Method | ||
| Cash | Checkbox |
Check this box if your wages were paid in cash.
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| Check | Checkbox |
Check this box if your wages were paid by check.
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| Direct Deposit | Checkbox |
Check this box if your wages were paid via direct deposit into your bank account.
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| Pay Card | Checkbox |
Check this box if your wages were paid onto a pay card.
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| Combination | Checkbox |
Check this box if your wages were paid using a combination of the listed methods, and provide an explanation.
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| Combination Payment Explanation | Text |
Provide a detailed explanation if your wages were paid by a combination of methods.
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| Wage Request Inquiry | ||
| Asked for Wages - Yes | Radiobutton |
Check this box if you did ask for your wages.
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| Asked for Wages - No | Radiobutton |
Check this box if you did not ask for your wages.
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| Wage Inquiry Explanation | Text |
Provide a detailed explanation of who was asked about your wages, when the request was made, and what the outcome or circumstances were.
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| Wage Statement Complaint | ||
| Provide a wage statement (pay stub) | Checkbox |
Check this box if the employer failed to provide you with a wage statement or pay stub.
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| Wage Statement Complaint Details | Text |
Enter details explaining the employer's failure to provide a wage statement or pay stub.
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| Wages for Hours Worked Over 40 | ||
| 35c Yes Wages for Hours Worked Over 40 | Radiobutton |
Check this box if you were paid any wages for the hours worked over 40.
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| 35c No Wages for Hours Worked Over 40 | Radiobutton |
Check this box if you were not paid any wages for the hours worked over 40.
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| Hourly Rate for Overtime | Number |
Enter the hourly wage you were paid for hours worked over 40.
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| Wednesday Workday Details | ||
| Wednesday Workday Start Hour | Text |
Enter the hour when the workday started on Wednesday.
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| Wednesday Workday Start Minute | Text |
Enter the minute when the workday started on Wednesday.
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| Wednesday Workday Start AM/PM | Text |
Enter 'AM' or 'PM' to indicate the time of day the workday started on Wednesday.
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| Wednesday Workday End Hour | Text |
Enter the hour when the workday ended on Wednesday.
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| Wednesday Workday End Minute | Text |
Enter the minute when the workday ended on Wednesday.
|
| Wednesday Workday End AM/PM | Text |
Enter 'AM' or 'PM' to indicate the time of day the workday ended on Wednesday.
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| Wednesday Time Off for Meals | Number |
Enter the total time taken off for meals on Wednesday.
|
| Wednesday Total Hours Worked | Number |
Enter the total number of hours worked on Wednesday.
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| Weekly Hours Consistency | ||
| 36a. Weekly Hours Consistent - Yes | Radiobutton |
Check this box if the hours worked, as listed in the table, are the same every week.
|
| 36a. Weekly Hours Consistent - No | Radiobutton |
Check this box if the hours worked, as listed in the table, are not the same every week.
|
| Average Weekly Hours | Number |
Provide your estimate of the average number of hours worked per week.
|
| Weekly Total Hours | ||
| Weekly Total Hours | Number |
Enter the total number of hours worked for the entire week.
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| Worksite Address | ||
| Worksite Street Address | Text |
Enter the primary street address of the worksite.
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| Worksite Floor/Room/Suite Number | Text |
Enter the floor, room, or suite number of the worksite, if applicable.
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| Worksite City/Town | Text |
Enter the city or town of the worksite.
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| Worksite County | Text |
Enter the county where the worksite is located.
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| Worksite State | Text |
Enter the state where the worksite is located.
|
| Worksite Zip Code | Text |
Enter the zip code of the worksite.
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