English Instructions & Guide

Summary

English Instructions & Guide

Text

LABOR COMMISSIONER, STATE OF CALIFORNIA 
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT 
INSTRUCTIONS FOR FILING A WAGE CLAIM
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 “Guide to Completing Initial Report or Claim Form” (attached to these Instructions).
2) 	 Along with your completed “Initial Report or Claim” Form,	
  submit these additional DLSE	
  Forms if any of the following
situations	
  apply to you:
o	  If your work hours and/or days of work varied or were irregular, and you are claiming unpaid	
  wages (for
overtime or non-­overtime hours worked) or meal and	
  rest	
  period violations , then also fill out and submit the
DLSE Form 55. 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.
o  If you are claiming commission pay, then also fill out and submit the DLSE Form 155.
o	  If you are claiming vacation wages, then also fill out and submit the DLSE “Vacation Pay Schedule” form.
o	  If you are represented by an attorney, you may submit	
  a calculation prepared by your attorney in lieu of	
  the above
computation forms.
3) 	 Along with your completed “Initial Report or Claim” Form, submit one COPY of the following documents,	
  if you have them
(DO NOT	
  SEND	
  ORIGINAL DOCUMENTS):
o	  Time records. 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	  Paychecks and	
  Pay Stubs. Provide a COPY of any paychecks and	
  pay stubs	
  you received showing the wages	
  you
were paid during your claim period.
o	  Dishonored (or “Bounced”) Paycheck(s). 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.
o	  Notice of Employment Information. 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 responsibility to keep accurate employee time and payroll records,	
  and to provide 
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 union contract, provide a copy of your Collective Bargaining Agreement.
WHAT TO EXPECT	
  AFTER	
  YOU FILE YOUR	
  CLAIM
1)  Settlement C
onference. In most	
  cases, you will receive a Notice from the Labor Commissioner setting a date and 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 copy (not the original) of any
document that supports your claim, but do not bring documents you have already submitted	
  with	
  the Initial Report or
Claim Form.
2) 	 Hearing. If your claim does not	
  settle at	
  the Conference and has a legal basis to proceed to a hearing, you will 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 original documents plus two
sets	
  of copies 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 
1. Public Works. An employee or former employee can	
  file a complaint for prevailing wages that were not paid	
  on a public works
project. “Public works” as defined	
  in	
  Labor Code Sections 1720 to	
  1720.3 include “construction, alteration, demolition,
installation, or repair work done under contract and	
  paid	
  for in	
  whole or in	
  part out of public funds.” If you worked on a public
works project, you should STOP here.	
   Do not fill	
  out this form but instead, please fill	
  out the PW-­‐1	
  claim form (entitled	
  “Public
Works – Initial	
  Report”). You may ask DLSE	
  staff for a copy of the PW-­‐1	
  form or download it at:
http://www.dir.ca.gov/dlse/HowToFilePWComplaint.htm
2. Retaliation. It is unlawful	
  for an employer to retaliate or discriminate against you (for	
  example, fire, threaten to fire,	
  demote,
suspend or discipline you) because you complain about your working conditions,	
  file a wage claim with DLSE,	
  or provide
information to DLSE or any government agency about your working	
  conditions. Check the “YES” box if you have filed a
retaliation complaint	
  with the Labor	
  Commissioner, and enter	
  the date	
  you	
  filed	
  the	
  complaint. If you have not filed a
retaliation complaint	
  but	
  would like to file one, you	
  may ask DLSE staff for a copy of the retaliation	
  complaint form or download
it at: http://www.dir.ca.gov/dlse/HowToFileRetaliationComplaint .htm
3. Union Contract? Check “YES” if your employment was covered by a union	
  contract. If you checked “YES,” then attach a copy of
the Collective Bargaining Agreement.
4. Other Employees Filing Wage Claims? Check “YES” if you know that other employees are filing wage claims against your
employer. 
PART 1: Language Assistance & Representation 
5 a. Interpreter Needed? Check “YES” if your primary language is not English and you want an interpreter to assist you. 
b. Language. If you checked “YES” to Box 5a indicating that you need an interpreter,	
  enter the language of the interpreter needed.
6 a. Name of Advocate. If you are being assisted with your claim by a lawyer or other advocate,	
  enter the name	
  and	
  organization of 
the person who is assisting you. 
b. Phone	
  Number of Advocate. If you are being assisted with your claim by a lawyer or other advocate, enter the phone number
at which you
r advocate	
  can be	
  contacted.
c. Mailing Address of Advocate. If you are being assisted with your claim by a lawyer or other advocate,	
  enter the mailing
address of y
our lawyer or other advocate. Include the street name and number, as well as any	
  floor or suite number, city, state,
and zip code. DLSE	
  will mail copies of information related to your claim to the	
  address of your advocate	
  that you enter here.
PART 2: Your In formation 
7. Your First Name. Enter your first	
  name.
8. Your Last N
ame. Enter your last name.
9. Your Home P
hone Number. Enter your home	
  telephone	
  number, with	
  ar ea code.
10. Other Phone Number. Enter the phone number,	
  with area code,	
  of another phone a t which DLSE	
  can reach you (for example, a
cell phone that you use).
11. Your Date of Birth. Enter your date	
  of birth. Inclu de the month, day, and year.
12. Your Mailing	
  Address. Enter your mailing address. Include the street name and number,	
  as well	
  as any floor or apartment
number, city,
 state, and	
  zip	
  code. DLSE will mail copies of information	
  related	
  to	
  your claim to	
  your address that you	
  enter here.
You must inform DLSE	
  immediately of any change in	
  your mailing	
  address.
PART 3: Claim Filed Against (Employer Information) 
13. Employer/Business Name(s). Enter the complete name of  your employer against whom you are filing the claim,	
  to the best of
your knowledge. If your employer has more than one business name (including	
  a “doing	
  business as”	
  or DBA name), list all
names that you	
  know. 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.
14. Employer License Plate Number. Enter your employer’s vehicle license plate num ber, if you know	
  this information.
15. Phone	
  Number of Employer. Enter the telephone number of your employ er,	
  with area code, if you know this information.
16. Address of Employer/Business. Enter the last  known address of your employer. List the street name;	
  number;	
  floor, suite or
room number	
  (if	
  any); city; state; and zip code. This address may be different	
  from the address where you worked (which you
should list in Box 17). If you are a garment worker or car wash worker, and your employer has changed its business address
since you worked for the employer, list both the new business address and the previous address,	
  if you know this information.
17. Address Where You Worked. Enter the ad dress where you performed work, if different from the address you listed in Box	
  16.
List the	
  street name; number; floor, suite	
  or room number (if any); city; state; and zip code.
18. Name of Person in Charge. Enter the first	
  and last	
  name of	
  the person in charge at the location  where you worked,	
  if you know
the name. This could be the owner,	
  your supervisor,	
  a manager,	
  or another person who ran the business or oversaw your work.
19. Job Title/Position of	
  Person in Charge. Enter the jo b title of the person in charge,	
  if known. Example:	
  “Floor Manager.”
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 
20.	 Type	
  of Business. Enter the type of	
  business or industry in which you worked for your employer. 
21.	 Type	
  of Work	
  Performed. Enter the type of	
  work you did for your employer. 
22.	 Total Number of Employees. Enter the approximate total	
  number of workers employed by your employer,	
  if you	
  know. 
23.	 St
ill in Business? Check “YES” if you know that your employer is still	
  operating its business. 
24.	 Description of Business Entity. Check the box indicating whether your employer is a corporation,	
  individually owned,	
  a 
partner
ship, a limited	
  liability company (LLC),	
  or limited liability partnership (LLP),	
  if you know this information.	
  
Part 4: Final Wages / Bounced Checks 
25.	 Date of Hire. Enter the month, d ay, and year that	
  you were hired by your employer. 
26.	 Employment Status. Indicate whether you still wo rk for your employer;	
  whether you quit your job (include the date that you 
quit); whether you	
  were discharged	
  (include the date that	
  you were discharged); or	
  whether	
  another	
  situation applies (check 
the “other” box and briefly specify your	
  situation	
  – for example,	
  “on disability leave”). 
27 a. Quit with 72	
  Hours Notice? If you quit with 72 hours notice,	
  check “YES.” 
b. Date of Final Paycheck. If you quit,	
  check “YES” if you have received your final	
  paycheck including all	
  wages owed,	
  and then	
  
enter th
e	
  month, day, and year that	
  you received your final paycheck. Under the law, if you quit with 72 hours notice (and 
you do not have a written contract for a definite period of employment), your final paycheck	
  is due at the time of quitting. If 
you	
  quit without giving 72 hours notice (and you do not have a written contract for a definite period of employment),	
  your 
final paycheck is due no later	
  than 72 hours after	
  quitting. 
28. Discharged? If you  were discharged,	
  check “YES” if you have received your final paycheck	
  including	
  all wages owed, and then 
enter the	
  month, day, and year that	
  you received your final paycheck. Under the law, if you were discharged, your final 
paycheck is due and	
  payable immediately. 
29 a. Method of Payment. Check the box to indicate if you were paid by:	
  check,	
  cash,	
  both check and cash,	
  or other method. 
b. Paycheck	
  Could Not Be Cashed? Check “YES” if you were paid by check and any of your paychecks could not be cashed 
because your employer has no account with the	
  bank or insufficient funds in the	
  account from which the check was drawn. 
Part 5: Hours You Typically Worked 
30.	 Usually Worked the Same Hours? Check the box indicating whether you usually worked the same hours and days per week,	
  or 
instea
d whether your work hours and/or days of work varied per week or were irregular.	
   If your work hours or days of work 
were irregular and you are claiming unpaid wages (for overtime	
  or non-­‐overtime	
  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). 
31.	 Your Typical Work	
  Hours. Fill	
  out t his table ONLY if you generally worked the same number of hours per week. (If your work 
hours were too	
  irregular to	
  estimate a typical workweek, DO NOT fill out	
  this table, but	
  fill out	
  the DLSE Form 55 instead.)	
   For 
each	
  day	
  that you worked in your typical workweek, give your best estimate of the times that you started and stopped 
working, and that you took for an uninterrupted meal period of at least 30 minutes in which you were relieved of all duty. 
•	 “DAY 1”	
  is the first day	
  of your  workweek, “DAY	
  2” is the second day	
  of your workweek, and so on. A workweek is any 7 
consecutive 24-­‐hour periods, starting with	
  the same calendar day each	
  week, beginning at any hour on any day, so	
  long as it 
is fixed and regularly recurring.	
   If you do not know what your workweek is and it is not established by your employer,	
  DLSE 
will use the calendar week starting from 12:01 a.m. on Sunday to midnight on Saturday, with each workday ending at 
midnight; thus, “DAY 1” of your workweek would be Sunday; “DAY 2” of your workweek would	
  be Monday, and	
  so on. 
•	 Time	
  work	
  started	
  and	
  ended. For each day that you worked in your typical	
  workweek,	
  enter the time you typically began 
and end
ed your day of work, and check the	
  corresponding	
  box for either “am” or “pm.” 
•	 1st meal period	
  start and end	
  time. For eac h day that you worked in your typical	
  workweek,	
  if you took an uninterrupted 
meal period of at least 30 minutes in which you were relieved of all duty, enter the time you typically began and ended your 
meal period, and check the corresponding box for either “am” or “pm.” 
•	 2nd meal period	
  start and end	
  time. For eac h day that you worked in your typical	
  workweek,	
  if you took a second 
uninterrupted	
  meal period	
  of at least 30 minutes in	
  which	
  you	
  were relieved of all duty, enter the time you typically	
  began 
and ended your meal period, and check the	
  corresponding	
  box for either “am” or “pm.” 
•	 ONLY IF YOU WORKED A SPLIT SHIFT. For eac h day that you worked in your typical	
  workweek,	
  enter the time your 1st	
  
shift ended (under “1st Shift ended	
  at”) and check	
  the	
  box	
  for either “am”	
  or “pm.”	
   Then enter the	
  time your 2nd shift	
  
began (under “2nd Shift started	
  at”) and check	
  the	
  box	
  for either “am”	
  or “pm.”	
   Example: Your employer scheduled you 
to work 2 shifts on the	
  same	
  workday, from 8 am to 12 pm, and then from 5 pm to 9 pm. Under “1st Shift ended	
  at” enter 
“12 pm.” Under “2nd Shift started	
  at” enter “5 pm.” If you did not work a split shift,	
  do not fill	
  out these boxes. 
Part 6: Payment of Wages 
32.	 Fixed Amount (“Salaried”
  Employee)? Check “YES” if you were paid or promised a fixed amount of wages regardless of the 
number of hours you	
  worked. Then	
  enter how much	
  money you	
  were actually	
  paid, and how frequently (such as per day or 
every 2 weeks, etc.). If you were promised a different amount, enter that amount, and how frequently	
  you were to be paid.

LABOR COMMISSIONER, STATE OF CALIFORNIA 
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT 
33a. Hourly	
  Pay? Check “YES” if you were paid by the hour. Then enter how much you were actually paid per hour. If you were	
  
promised	
  a different hourly pay than	
  you	
  received, also	
  enter that amount. 
b. More than One Hourly Rate? Check “YES” if you were paid or promised various hourly rates,	
  based on your hours worked or 
diffe
rent job	
  tasks, then briefly describe your situation. Example: “Paid $10 per hour for	
  30 hours unloading truck, and $8 
per hour for 15 hours checking inventory.” 
34.	 Paid by Piece	
  Rate? Check “YES” if you were paid by piece rate. 
35.	 Paid by Commission? Check “Y ES” if you	
  received	
  commission	
  pay. 
Part 7: Wages, Compensation & Penalties Owed 
36. Claim(s) and Amount(s). (NOTE: For c laims marked by ***,	
  attach a separate computation form. For vacation pay,	
  fill	
  out the 
“Vacation Pay	
  Schedule”	
  form; for commission	
  pay, fill out the DLSE Form 155.) 
•	 Check the	
  box for each claim you are	
  making, and fill in the	
  claim period and amount earned / claimed. 
o	  NOTE: Meal period wages. An employer may not require any employee to work during any meal	
  period mandated by 
an applicable	
  order of the	
  Industrial Welfare	
  Commission (IWC). If an employer fails to provide	
  an employee	
  with a 
meal period in accordance with an applicable order of the IWC,	
  a non-­‐exempt employee	
  may seek one	
  additional hour 
of pay at the employee’s regular rate of compensation	
  for each	
  workday that the meal period	
  is not provided. Under 
most IWC orders, an employer may not employ any person for a work period of more	
  than five	
  (5) hours without a 
meal period of not less than 30 minutes, or for a work period of more than ten (10) hours without providing a second 
meal period of not less than 30 minutes, subject to certain waivers by mutual consent or other exceptions. The 
employee	
  must be	
  relieved of all duty during	
  the	
  30-­‐minute meal period. Check the	
  IWC	
  order that applies to you. No 
matter how many meal periods are missed in one workday, only one meal period premium	
  is imposed for that day. 
o	  NOTE: Rest period wages. In general, the IWC orders require employers to authorize and permit non-­‐exempt 
employees to take	
  rest periods, which insofar as practicable	
  shall be	
  in the	
  middle	
  of each work period. If an employer 
does not provide an	
  employee a rest period	
  in	
  accordance with	
  an	
  applicable order of the IWC, a non-­‐exempt 
employee	
  may seek one	
  additional hour of pay at the employee’s regular rate of compensation	
  for each	
  workday that 
the rest	
  period is not	
  provided. The authorized rest	
  period time shall be based on the total hours worked daily at	
  the 
rate of	
  ten (10)	
  minutes net	
  rest	
  time per	
  four	
  (4)	
  hours or	
  major	
  fraction thereof. For example, the	
  total amount of 
rest	
  period time required is 10 minutes if	
  you work more than two hours and up to six hours; 20 minutes if	
  you work 
more than six hours and up to 10 hours; 30 minutes if you work more than	
  10 hours and	
  up to	
  14 hours. However,	
  a 
rest	
  period does not	
  need to be authorized for	
  employees whose total daily work time is less than three and one-­‐half 
(3.5)	
  hours. In addition,	
  certain employees are	
  subject to special rest	
  period rules.	
   Check the	
  IWC	
  order that applies 
to you. Authorized	
  rest period	
  time is counted as hours worked and should not be deducted from wages. No matter 
how many rest periods are missed	
  in	
  one workday, only one rest period	
  premium is imposed	
  for that day. 
•	 Subtotal. Add	
  togethe r all amounts earned/ claimed, and	
  enter this subtotal. 
•	 Total Amount Paid. If your e mployer paid you any compensation relating to your claim(s),	
  enter the total	
  amount paid. 
For any wages paid, enter the	
  gross amount paid to you. 
•	 Grand Total	
  Owed. F rom the Subtotal of amounts earned/ claimed,	
  subtract the Total Amount Paid. 
37. Penalties. Check  the box(es) if you are	
  also claiming: 
•	 Waiting time penalties [Labor Code Section 203]. You ma y be able to recover waiting time penalties if you were 
discharged	
  or quit and	
  your employer willfully failed	
  to	
  pay your wages either: at the time you	
  were discharged; at the time 
of quitting if you	
  gave 72 hours notice; or 72 hours after quitting if you	
  did	
  not give notice. The wages of the employee 
continue as a penalty from their due date at the same rate until paid	
  or until an	
  action	
  is filed	
  in	
  court. Penalties may 
continue for up to 30 calendar days	
  and are computed by	
  multiplying the employee’s	
  daily	
  wage rate by	
  the number of days	
  
since the payment of wages became due. 
•	 Penalties for “bounced” or dishonored checks [Labor Code	
  Section 203.1]. You may be able to recover such penalties if 
you we
re 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,	
  and you attempted to cash that check within 30 days of 
receiving it. You	
  may be entitled	
  to	
  recover a penalty of one day’s pay for each	
  day those wages remain	
  unpaid	
  or until an	
  
action is commenced, up to 30 calendar days. 
SIGN & DATE THE FORM. 
(7/2012)

Retrieval chunks

• #1

  LABOR COMMISSIONER, STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT INSTRUCTIONS FOR FILING A WAGE CLAIM 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 “Gui…

• #2

  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 responsibility to keep accurate em…

• #3

  1. Public Works. An employee or former employee can file a complaint for prevailing wages that were not paid on a public works project. “Public works” as defined in Labor Code Sections 1720 to 1720.3 include “construction, alteration, demolition, installation, or repair work done under contract and paid for i…

• #4

  our lawyer or other advocate. Include the street name and number, as well as any floor or suite number, city, state, and zip code. DLSE will mail copies of information related to your claim to the address of your advocate that you enter here. PART 2: Your In formation 7. Your First Name. Enter your first name.…

• #5

  street name; number; floor, suite or room number (if any); city; state; and zip code. 18. Name of Person in Charge. Enter the first and last name of the person in charge at the location where you worked, if you know the name. This could be the owner, your supervisor, a manager, or another person who ran the…

• #6

  28. Discharged? If you were discharged, check “YES” if you have received your final paycheck including all wages owed, and then enter the month, day, and year that you received your final paycheck. Under the law, if you were discharged, your final paycheck is due and payable immediately. 29 a. Method of Paym…

• #7

  enter the time you typically began and end ed your day of work, and check the corresponding box for either “am” or “pm.” • 1st meal period start and end time. For eac h day that you worked in your typical workweek, if you took an uninterrupted meal period of at least 30 minutes in which you were relieved of…

• #8

  35. Paid by Commission? Check “Y ES” if you received commission pay. Part 7: Wages, Compensation & Penalties Owed 36. Claim(s) and Amount(s). (NOTE: For c laims marked by ***, attach a separate computation form. For vacation pay, fill out the “Vacation Pay Schedule” form; for commission pay, fill out the …

• #9

  need to be authorized for employees whose total daily work time is less than three and one-­‐half (3.5) hours. In addition, certain employees are subject to special rest period rules. Check the IWC order that applies to you. Authorized rest period time is counted as hours worked and should not be deducted …