Form LL-1: Wage Claim - Texas Workforce Commission

TEXAS WORKFORCE COMMISSION
WAGE CLAIM INFORMATION
TEXAS PAYDAY LAW
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
Wage problems can often be cleared up by discussing them with your employer. 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.
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
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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 dismissed.
Your wage claim is without your signature and a completed declaration that the information is true, under penalty of
perjury.
You acted as an “independent contractor” and not as 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 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.
You file against more than one employer on one claim form. Use separate wage claim forms for filing against each employer.
MAIL YOUR COMPLETED WAGE CLAIM TO:
Texas Workforce Commission, Labor Law Section
101 East 15th Street, Room 124T
Austin, TX 78778-0001
OR
FAX YOUR COMPLETED WAGE CLAIM TO:
1-512-475-3025
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 attached timesheet. 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.
TITLE 2, CHAPTER 61, TEXAS LABOR CODE, PROVIDES THAT A PENALTY
MAY BE ASSESSED FOR WAGE CLAIMS BROUGHT IN BAD FAITH.
LL-1 (0514) Inv. No.621750
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
Start Time
Hour
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
Week 2
Start Time
Hour
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 a breakdown for commission or bonus.
(Example: customers/sales/accounts X 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.
LL-1 (0514) Inv. No.621750
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
(PURSUANT TO TITLE 2, CHAPTER 61, TEXAS LABOR CODE)
PLEASE WRITE CLEARLY IN INK. Note: Social Security Number is optional, but failing to include it will delay processing of your claim.
CLAIMANT INFORMATION:
INFORMATION ABOUT YOUR EMPLOYER:
Your Name
(First)
(Middle)
Business Name
(Last)
Address
Owner’s Name
Apartment #
Business Address
City
State
Zip
Social Security Number
City
Home Phone
Employer's Phone
(
)
Birthdate
(MM
DD
State
(
Zip
)
Work Location
YY)
Current Work or Cell Phone
PLEASE COMPLETE THE FOLLOWING EMPLOYMENT INFORMATION:
1. What work did you perform?
2. Beginning date of employment
Employment status with this employer:
Reason for separation:
Still employed
Quit date
Termination date
3. 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./day,
Days/wk,
4. Was your compensation agreement
Oral
5. Were the claimed wages earned in Texas?
If not, was the job contracted in Texas?
6. Were taxes deducted from your paycheck?
7. Is the employer still in business?
other
Written (please attach a copy)
Yes
No
Yes
No
Yes
No
Yes
No
What are the employer’s home address and phone number?
8. Is the employer in bankruptcy?
Yes
No
9. What were the name and phone number of your supervisor during the period claimed?
10. If you are related to the employer, please state the relationship.
11. Did the employer give a reason for not paying you? If so, explain:
12. 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, since expenses 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.
LL-1 (0514) Inv. No.621750
(Cont inued on Back)
13. What was the scheduled payday(s) for these claimed wages? Date(s)
14. 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
each amount claimed. (Example: 20 hours regular pay at $5 per hour and 5 hours overtime pay at $7.50 per hour.
Example: 30 items at a piece rate of $.75 per item).
Please attach the check stubs or earnings statement.
15. If claiming commission, what was the period in which the wages were earned?
From
to
_.
Indicate how you determined the
amount due (attach information to support your claim, such as sales records, check stubs, etc.). ______
16. If claiming a bonus, was the bonus a part of your employment agreement or a casual gift?
If based on performance, what was the period in which the bonus was earned?
From
to
.
Please furnish details of the bonus (include a copy).
17. If claiming a covered fringe benefit, please explain which benefit(s) you are claiming and why you are entitled to the wages.
Please indicate how you determined the amount due and attach a copy of the employer’s written agreement or policy
concerning the type of fringe benefits(s) claimed.
18. If claiming deductions, did you sign any authorization for deductions other than regular payroll taxes?
If yes, please explain (attach a copy).
19. Are you in bankruptcy?
Chapter:
Yes
No
Case No:
Yes
No
If yes, what is your bankruptcy filing date?
Where filed:
What are your bankruptcy attorney’s name, address, and phone number?
20. 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 of the agreement.
21. 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
__________
(First)
and my address is
__________
(Middle)
______________, my date of birth is
(Last)
_____________________,
(Street)
________,
(City)
____________
(month/day/year)
____,
(State)
____, and
___________.
(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 787780001, (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.