Form LL-1: Wage Claim Form - Texas Workforce Commission

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.