TEXAS WORKFORCE COMMISSION WAGE CLAIM INFORMATION TEXAS PAYDAY LAW Este formulario está disponible en español IMPORTANT! YOUR CLAIM MUST BE SIGNED AND DECLARED AS TRUE UNDER PENALTY OF PERJURY. YOU MUST FILL OUT THE FORM COMPLETELY. INFORMATION YOU SHOULD CONSIDER BEFORE FILING A WAGE CLAIM IF YOU FEEL YOUR RIGHTS UNDER THE PAYDAY LAW HAVE BEEN VIOLATED, YOU MAY FILE A WRITTEN WAGE CLAIM. YOU SHOULD KNOW THAT A WAGE CLAIM CANNOT BE ACCEPTED IF: • Your wage claim is not filled out completely, legibly and accurately, and signed and declared as true under penalty of perjury. The claim should identify each type of unpaid wage claimed, and how you determined the amount due to you. If there is insufficient information on the wage claim to contact the employer, your claim will be returned or dismissed. • Your wage claim is without your signature and a completed declaration that the information is true, under penalty of perjury. • You’re an “independent contractor” and not an “employee” of the business. (if you are unsure, file a claim and we will determine if you were an independent contractor or an employee) • You were employed by a close relative (such as: mother, grandfather, or father-in-law). (if you are unsure, file a claim and we will investigate the circumstances) • Your employer filed for bankruptcy. (if you are unsure, file a claim but you may also need to file proof of claim directly with the Bankruptcy Court) • You were employed by the federal government, the state, or a political subdivision of the state. • Your wages are subject to a binding arbitration or collective bargaining agreement or contract. (if you are unsure, file a claim and include the agreement or contract and we will investigate the circumstances) • Your wage claim is filed later than the 180th day after the date the unpaid wages were due to be paid. If part of your claim is within 180 days, file only for that part. • Your wage claim is for subsequent pay periods. You can amend this claim prior to a preliminary wage determination order. Do not file another wage claim. • You file against more than one employer on one claim form for a different pay period. • Your wage claim is not for wages but for expenses, reimbursements or automobile allowances. MAIL YOUR COMPLETED WAGE CLAIM TO: OR FAX YOUR COMPLETED WAGE CLAIM TO: Texas Workforce Commission, Labor Law Section 1-512-475-3025 101 East 15th Street, Room 124T Austin, TX 78778-0001 Call 1-800-832-9243, 1-512-475-2670, or TDD 1-800-735-2989 (hearing impaired) if you need assistance. Please attach a copy of your most recent payroll check or stub. For regular hours and overtime hours, please attach a breakdown of the days and hours of work or complete the Wage Claim Form Attachment. If your address or phone number changes, it is your responsibility to notify Labor Law in writing immediately. If you cannot be contacted, the likelihood of collecting unpaid wages will be reduced. Wage problems can often be cleared up by discussing them with your employer. For additional information visit our web site at http://www.twc.state.tx.us/jobseekers/how-submit-wage-claim-under-texas-payday-law. Before filing a claim for unpaid wages, you may want to advise your employer that the Texas Payday Law, Title 2, Chapter 61, Texas Labor Code provides that: 1. Your employer must pay you at least once a month if you are not subject to the overtime provisions of the Fair Labor Standards Act. All others must be paid at least semimonthly. 2. If you are absent on payday, you are entitled to be paid at your request on a regular business day. 3. If you leave your work for a reason other than by discharge, you must be paid in full not later than the next regularly scheduled payday. 4. If discharged, you must be paid in full not later than the sixth day after termination. 5. Bonuses or wages paid on a commission basis are due in a timely manner, according to the terms of agreement entered into between employee and employer. 6. You may be entitled to unpaid wages for unused “fringe benefits” (vacation, holiday, sick leave, parental leave, or severance pay), only if your employer provides for these benefits in a written policy or agreement. 7. Your wages may be withheld only if the employer: a. Is ordered to do so by a court; b. Is authorized by state or federal law (e.g. payroll taxes); or c. Has your written authorization to make the deductions. LL-1 (0416) Inv. No.621750 TITLE 2, CHAPTER 61, TEXAS LABOR CODE, PROVIDES THAT A PENALTY MAY BE ASSESSED FOR WAGE CLAIMS BROUGHT IN BAD FAITH. Wage Claim Form Attachment Question #14 Hours Worked Per Week Breakdown Instructions: Enter the date of the starting day of the first workweek Enter the start time for the first day on the time card o Enter the starting hour in the Hour column o Enter the minutes in the Min column o Enter AM or PM in the AM/PM column Example: If you started working at 8:30am enter; Hour Min AM/PM 8 30 AM Enter the stop time for any break or lunch period in the Stop Time section; following the example above Enter the start time when returning to work from any break or lunch period in the Start Time 2 section Enter the ending time in the Quit Time section Enter the total number of hours worked for the date Enter the total number of hours worked for the entire workweek Week 1 MM/DD/YY Hour Ex: 12/01/15 8 Start Time Stop Time Start Time 2 Hours Worked Quit Time Min AM/PM Hour Min AM/PM Hour Min AM/PM Hour Min AM/PM 00 AM 12 00 PM 1 00 PM 5 00 PM 8 Total weekly Hours Week 2 MM/DD/YY Hour Start Time Min Stop Time AM/PM Hour Min AM/PM Start Time 2 Hour Min AM/PM Quit Time Hour Min Hours Worked AM/PM Total weekly Hours Question #15 & 16 Commission or Bonus breakdown Please include supporting information and mathematical computation for commission or bonus. (Example: customers/sales/accounts X (multiplied by) commission/bonus rate = commission or bonus due on a sale) Please include supporting information for mileage, such as log sheets or city-to-city trips. If you need additional spreadsheets, please make copies. Wage Claim TEXAS WORKFORCE COMMISSION, LABOR LAW SECTION 101 EAST 15TH STREET, AUSTIN, TEXAS 78778-0001 Telephone 1-800-832-9243 or 1-512-475-2670 or TDD 1-800-735-2989 (Hearing Impaired); Fax 1-512-475-3025 www.texasworkforce.org (PURSUANT TO TITLE 2, CHAPTER 61, TEXAS LABOR CODE) Este formulario está disponible en español PLEASE WRITE CLEARLY IN INK. Note: Social Security Number is optional, but failing to include it will delay processing of your claim. I want TWC to send future correspondence in: English Spanish CLAIMANT INFORMATION: First Name: Middle: Address: Apt #: Date of Birth (MM/DD/YY): __/__/__ Quiero que TWC envíe toda futura correspondencia en: Inglés Last Name: City: Social Security # (Optional): - State: Phone # Where you can be reached during - Suite #: Zip: Alternate Phone # Where you can be reached normal business hours. INFORMATION ABOUT YOUR EMPLOYER: Business Name (If incorporated) Owner’s First Name (If sole proprietor or partnership): Owner’s Business Address: Español during normal business hours. Owner’s Last Name: City: State: YOUR Work Location (Street Address, City, State, Zip): Zip: Employer’s Work Phone #: Employer’s E-mail or Web Address: 1. PLEASE COMPLETE THE FOLLOWING EMPLOYMENT INFORMATION: What work did you perform? Beginning date of employment Employment status with this employer: Still employed Quit date Termination date Reason for separation: When were your regularly scheduled paydays? What was your rate of pay? (Examples: $3/hour, $1,000/month, $.50/piece, $2/sq. ft.) What was the agreed work schedule? Hrs. per day, Days per wk, other Was your compensation agreement Oral Written (please attach a copy) Were the claimed wages earned in Texas? Yes No If not, was the job contracted in Texas? Yes No Were taxes deducted from your paycheck? Yes No Is the employer still in business? Yes No What is the employer’s home address and phone number? _________ __________________________________________________________________________________________________________________________________________________________________________ _______ __________________________________________________________________________________________________________________________________________________________________________ ____ ________ 2. ____________________ _____ ______________________________________________________________________________________________________________________________________________ ______ 5. 6. _____________ ________________________________________________________________________________________________________________________________________________________________________________________ ______ 3. 4. ____ _________________ ________ _____ __ ___ ______________________________________________________________ ___ _____ _______ _________ ____________________________________________________________________ ______________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What is the name and phone number of your supervisor during the period claimed? ____ ____________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 7. Is the employer in bankruptcy? Yes No If yes, what is the bankruptcy filing date? __ Are you in bankruptcy? _ No ____________________________________________________________ Chapter: Case No: Where filed: What is the bankruptcy attorney’s name, address, and phone number? _______________ Yes ______________________________________ ______ ______________________________________________________________________________________________ _______________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8. 9. If you are related to the employer, please state the relationship. Did the employer give a reason for not paying you? If so, explain: __ _______________________________________________________________________________________________ __________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ LL-1 (0416) Inv. No.621750 ( C o n t i n u e d o n B a c k ) 10. Choose the type(s) of unpaid wages below that best describe your claim, and write the amount of unpaid wages, listing the gross amount of wages due. Note: You cannot file for recovery of any type of expenses or reimbursement, since expenses and reimbursements are not wages. Regular $____ _______________ Overtime $______ Commissions $_________ _________________________ __________ Unpaid Bonus $_________ *Fringe Benefits $_____ ____________________ _________________ Pay Deductions $_________ Pay Below Minimum Wage $_________ __________ ____________________________ TOTAL UNPAID WAGES CLAIMED $_____________ ___________________________________ * The only fringe benefits that can be claimed are vacation pay, holiday pay, severance, sick leave, parental leave, paid time off, or paid days off. These benefits cannot be claimed unless provided for in a written agreement or a written policy of the employer. 11. What was the scheduled payday(s) for these claimed wages? Date(s) Date(s) ______ __________________________________________________________________________________________ 12. If claiming regular, overtime, and/or minimum wage, what were the dates you worked for which you received no wages? From to Please explain how you determined the amount claimed and provide a breakdown of the days and hours worked. (Example: 20 hours regular pay at $5 per hour and 5 hours overtime pay at $7.50 per hour; or Example: 30 items at a piece rate of $.75 per item). If available, attach a copy of timecards or timesheets. Use the attachment located on the backside of the instructions to provide a breakdown of the days and hours worked. ______ ____________________________________________________________________ ______ _______________ ______________________________________________________________. ____________________________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 13. If claiming commissions or bonus, what was the period in which the wages were earned? From ______ ____________________________________________________________________ to _______________ ______________________________________________________________. Are you aware of any agreement to pay commissions or bonus after termination? Yes No Please explain how you determined the amount due. If available attach information to support your claim, such as written agreement, sales records, check stubs, etc. Use the attachment located on the backside of the instructions to provide a breakdown of commissions or bonus. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ 14. If claiming a covered fringe benefit, please explain which benefit(s) you are claiming and indicate how you determined the amount due. We must obtain a copy of a written policy or agreement providing a payment after separation, please attach a copy. Also attach evidence of the amount owed (hours left) such as check stubs or other documents. ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 15. If claiming deductions, did you sign any authorization for deductions other than regular payroll taxes? Yes No If yes, please explain (attach a copy). __ ___________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 16. Are you aware of any agreement (such as arbitration, collective bargaining agreement, union contract, ERISA, Service Contract Act, etc.) that existed between you and the employer? Yes No If yes, please attach a copy. 17. Additional Comments: ___________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I UNDERSTAND THAT I MAY BE ASSESSED AN ADMINISTRATIVE PENALTY IF THIS CLAIM IS FOUND TO BE BROUGHT IN BAD FAITH. To be considered valid, your Wage Claim must be completed below and signed as true under penalty of perjury. My name is _ _________ _ ___________ _ ________________, my date of birth is _ ____________ (First) (Middle) (Last) (month/day/year) and my address is _ ____________________, _ ______, _ ___, __ __, and _ ____________. (Street) (City) (State) (Zip Code) (Country) I declare under penalty of perjury that the foregoing is true and correct. Executed in _ __________ County, State of __ ________, on the _ ______________________________ _ day of_ ___, (Month) ________. (Year) Declarant (signature) Completed forms, inquiries, or corrections to the individual information contained in this form shall be sent to the TWC Labor Law Section, 101 E. 15th St., Rm. 124T, Austin, TX 78778-0001, (512) 475-2670. Individuals may receive and review information that TWC collects about the individual by emailing to [email protected] or writing to TWC Open Records, 101 E. 15th St., Rm. 266, Austin, TX 78778-0001.
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