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D.C. OFFICE OF WAGE-HOUR: WAGE PAYMENT CLAIM FORM (Government of the District of Columbia)

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Page 1 of 5 OWH_WPForm Rev 01/20
D.C. OFFICE OF WAGE-HOUR: WAGE PAYMENT CLAIM FORM
Oficina de Salarios y Horas de Trabajo de D.C.: Formulario de Reclamación de Pago de Salario
PRELIMINARY QUESTIONS / PREGUNTAS PRELIMINARIAS
SECTION 1 PERSONAL INFORMATION/  
FULL NAME 
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER  
STREET ADDRESS   
CITY STATEZIP CODE  
DAYTIME PHONE NUMBER(S)/  
EMAIL ADDRESS/ 
SECTION 2 BUSINESS INFORMATION/  
BUSINESS NAME   
OWNER'S FULL NAME 
OWNER'S/BUSINESS PHONE #    
BUSINESS STREET ADDRESS  
CITY STATE ZIP CODE   
TYPE OF BUSINESS 
HOW MANY EMPLOYEES? CHECK ONE
LESS THAN 2525 TO 99100 OR MORE 
EMPLOYER’S EMAIL ADDRESS/ 
IS THE BUSINESS CLOSED OR IN BANKRUPTCY?/ YES
Complaint #: _____________________
Assigned To: ______________________
Date Assigned: ____________________
ID #:_____/_____
Official Use Only
DO YOU NEED INTERPRETATION/TRANSLATION SERVICES THROUGHOUT YOUR INVESTIGATION? YES NO
¿NECESITA SERVICIOS DE INTERPRETACIÓN Y/O TRADUCCIÓN A LO LARGO DE SU INVESTIGACIÓN? SI NO
WHAT IS YOUR PRIMARY LANGUAGE?___________
¿CUÁL ES SU IDIOMA PRINCIPAL?_________________
WERE YOU HIRED TO WORK AS A SUBCONTRACTOR OR WERE YOU SELF-EMPLOYED? YES NO
¿FUE CONTRATADO PARA TRABAJAR CÓMO UN SUBCONTRATISTA O TRABAJO POR SU PROPIA CUENTA? SÍ NO
STREET ADDRESS WHERE THE WORK WAS PERFORMED 
STREET
CITY/CUIDAD: ______________ STATE/ESTADO: ZIP CODE/CÓDIGO POSTAL: _______________________
Page 2 of 5 OWH_WPForm Rev 01/20
SECTION 3 EMPLOYMENT INFORMATION/  
(CHECK ONLY THE OPTION THAT APPLIES TO YOUR CURRENT EMPLOYMENT STATUS WITH THIS COMPANY/
  )
CURRENT RATE OF PAY 
PER HOUR?YES
PER DAY?YES
PER WEEK?YES
DATE HIRED --
EMPLOYMENT STATUS/ :
QUIT  YES
IF YES, WHY?
QUIT DATE--
TERMINATED YES
TERMINATION DATE--
IF YES, WHY?
STILL EMPLOYED/ YES
LAST DAY WORKED 
WHAT TYPE OF WORK DID YOU DO FOR THIS COMPANY?  
_________________________________________________________________________________________________________________________________________
WERE YOU MISCLASSIFIED AS AN INDEPENDENT CONTRACTOR?/
 YES
FULL NAME OF YOUR SUPERVISOR  
WHAT DAY IS PAYDAY? (I.E. FRIDAY/VIERNES)
HOW OFTEN ARE YOU PAID ?CHECK ONE
HOURLY DAILYWEEKLY
BI-WEEKLY- SEMI-MONTHLY-MONTHLY
WHEN DOES PAY PERIOD END?  
ARE YOU PAID BY CHECKCASHBOTH
WHAT IS YOUR WORK SCHEDULE? 



 I.E., MON, WED, FRI 10:00AM – 4:30PM, TUE & SAT 9:30AM-8:00PM WITH ½ HR LUNCH BREAK – INCLUDE ANY BREAKS
 -
DID YOUR EMPLOYER KEEP A RECORD OF THE HOURS YOU WORKED?/
¿MANTUVO SU EMPLEADOR UN REGISTRO DE HORAS QUE USTED TRABAJO? YES/SI NO
IF YES, WHAT KIND OF RECORD WAS IT?/¿SI ES SÍ, QUÉ TIPO DE REGISTRO ERA?
(FOR EXAMPLE: TIME CARD/ TIME SHEET/ ETC.) ____________________________________________________________________
Page 3 of 5 OWH_WPForm Rev 01/20
SECTION 4 TYPE OF CLAIM ARE YOU FILING / SECCIÓN 4 TIPO DE RECLAMACIÓN QUE ESTÁ PRESENTANDO
SECTION 5 RECORD OF WAGES OWED / SECCIÓN 5 REGISTRO DE SALARIOS ADEUDADOS
DO YOU HAVE ANY OUTSTANDING LOAN BALANCES DUE TO YOUR EMPLOYER?/
¿USTED TIENE ALGÚN TIPO DE PRÉSTAMO QUE LE DEBE A SU EMPLEADOR? YES/SÍ NO
IF YES, HOW MUCH?/¿SI ES SÍ, CUÁNTO? $______________________
DOES YOUR COMPANY HAVE A PAID TIME OFF POLICY (PTO)? YES/SÍ NO
¿TIENE SU EMPLEADOR UNA POLÍTICA DE PAGO POR TIEMPO LIBRE?
IF SO, HOW MANY PTO DAYS ______________
SI ES SI, DE CUANTOS DÍAS ____________________
(YOU MUST PROVIDE COPY(IES) OF PAY STUB(S) SHOWING THE DEDUCTION(S)/
USTED DEBE DE PROPORCIONAR COPIA(S) DE LOS TALONARIOS DE PAGO DEMOSTRANDO LA DEDUCCIÓN(S))
UNAUTHORIZED DEDUCTIONS/DEDUCCIONES NO AUTORIZADAS: YES/SÍ NO
DO YOU HAVE ANY EQUIPMENT BELONGING TO THIS EMPLOYER? /
¿TIENE USTED ALGÚN TIPO DE EQUIPO QUE LE PERTENEZCA A SU EMPLEADOR? YES/SÍ NO
WERE YOU AN OFFICER OF THE CORPORATION, OR A PARTNER IN THE BUSINESS? /
¿HA SIDO USTED UN FUNCIONARIO DE LA CORPORACIÓN O UN SOCIO EN EL NEGOCIO? YES/SÍ NO
ARE YOU FILING FOR YOUR WAGES?/ ¿USTED ESTÁ RECLAMANDO POR SU PAGO? YES/SÍ NO
FOR WHAT TIME PERIOD WERE YOU NOT PAID WAGES?/
¿POR QUÉ PERÍODO DE TIEMPO NO LE PAGARON SU SALARIOS? __________________________________ TO/A ______________________________
(FROM/DESDE MM/DD/YY) (MM/DD/YY)
PLEASE LIST WAGES OWED BY DATE /POR FAVOR LISTE LOS SALARIOS DEBIDOS POR FECHA (CHECK ONE/MARQUE UNO):
DAILY/DIARIO WEEK ENDING/FINAL DE SEMANA PAY PERIOD ENDING/FINAL DEL PERIODO DE PAGO PAYDAY/DIA DE PAGO
DATE(S) RATE OF PAY HRS AMOUNT DATE(S) RATE OF PAY HRS AMOUNT
FECHA(S) TASA DE PAGO HORAS CANTIDAD FECHA(S) TASA DE PAGO HORAS CANTIDAD
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
_____/_____/____-_____/_____/____ $__________ * _________ = $______________ _____/_____/____-_____/_____/____ $__________ * _________ = $______________
ADDITIONAL NOTES/ NOTAS ADICIONALES: ______________________________________________________________________________________
_______________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________
Page 4 of 5 OWH_WPForm Rev 01/20
SECTION 6 RECORD OF ADDITIONAL WAGES OWED / SECCIÓN 6 REGISTRO DE SALARIOS ADICIONALES ADEUDADOS
ARE YOU A TIPPED EMPLOYEE?/¿ES USTED UN EMPLEADO QUE RECIBE PROPINAS? YES/SÍ NO
ARE YOU OWED TIPS?/¿ SE LE DEBE PROPINAS? YES/SÍ NO
IF YES, LIST DATES/ SÍ ES SÍ, LISTA LAS FECHAS ____________________ TO/A _______________________
AMOUNT OF TIPS OWED/ CANTIDAD DE PROPINAS DEBIDO $ _____________________________________
DO YOU HAVE A BAD CHECK(S)?/ ¿USTED TIENE UN CHEQUE(S) SIN FONDOS?: YES/SÍ NO
CHECK #/NUMERO DEL CHEQUE: ______________ DATE OF CHECK/FECHA DEL CHEQUE: _____________
CHECK #/NUMERO DEL CHEQUE: ______________ DATE OF CHECK/FECHA DEL CHEQUE: _____________
CHECK #/NUMERO DEL CHEQUE: ______________ DATE OF CHECK/FECHA DEL CHEQUE: _____________
(YOU MUST PROVIDE A COPY OF THE BAD CHECK TO THIS OFFICE/ USTED DEBE PROVEER UNA COPIA DEL CHEQUE SIN FONDO A ESTA OFICINA)
ADDITIONAL NOTES/ NOTAS ADICIONALES:____________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________
IF YES, INDICATE TOTAL AMOUNT OF ALL BAD CHECKS /
SI ES SÍ, INDIQUE LA CANTIDAD TOTAL DE TODO LOS CHEQUES SIN FONDO: $________________________
ARE YOU OWED COMMISSIONS?/ ¿ LE DEBEN A USTED COMISIONES? YES/SÍ NO
(YOU MUST ATTACH A COPY OF EMPLOYER’S COMMISSION PLAN/
USTED DEBE DE ADJUNTAR UNA COPIA DEL PLAN DE COMISIÓN DEL EMPLEADOR)
IF YES, INDICATE AMOUNT/SÍ ES SÍ, INDIQUE CUÁNTO: $_________________________
HAVE YOU RECEIVED ANY ADVANCES ON THE WAGES DUE?/
¿HA RECIBIDO USTED ALGÚN ADELANTO DE DINERO DEL CUAL RECLAMA? YES/SÍ NO
IF YES, HOW MUCH?/ ¿SÍ ES SÍ, CUÁNTO? $_________________________
DOES YOUR COMPANY OFFER VACATION PAY OR PAID TIME OFF (PTO) PAYOUT?/
¿OFRECE SU EMPLEADOR PAGO DE VACACIONES O PAGO POR TIEMPO LIBRE?
YES/SÍ NO
(YOU MUST PROVIDE A COPY OF THE COMPANY’S VACATION POLICY/
USTED TIENE QUE PRESENTAR UNA COPIA DE LA POLITICA DE BENEFICIOS DE LA COMPAÑÍA)
IF SO, HOW MANY/ SÍ ES SÍ, CUÁNTO : HOURS/ HORAS ________ DAYS/ DÍAS ___________ WEEKS/ SEMANA ___________
AMOUNT OWED?/¿QUÉ CANTIDAD LE DEBEN? $___________________________
TOTAL AMOUNT OF UNPAID WAGES YOU ARE CLAIMING/
 
HAVE YOU DEMANDED YOUR UNPAID WAGES?/
¿HA EXIGIDO USTED EL PAGO DE SU SALARIO? YES/SÍ NO
WHAT REASON DID THE EMPLOYER GIVE FOR NOT PAYING YOU?/ ¿QUE RAZÓN LE DIO EL EMPLEADOR PARA NO PAGARLE?
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Page 5 of 5 OWH_WPForm Rev 01/20
SECTION 7 VERIFICATION SHEET/ SECCIÓN 7 HOJA DE VERIFICACIÓN
YOUR CLAIM WILL BE REVIEWED FOR ADMINISTRATIVE ACTION ACCORDING TO DC CODE § 32-1308.01. ADDITIONAL
INFORMATION MAY BE REQUESTED.
    §-
 
UNDER PENALTY OF PERJURY, I SWEAR OR AFFIRM THAT THE INFORMATION I HAVE GIVEN ON THIS COMPLAINT FORM IS TRUE AND ACCURATE. I
AUTHORIZE THE DOES OFFICE OF WAGE-HOUR TO RELEASE ANY AND ALL INFORMATION CONTAINED IN MY COMPLAINT FILE TO MY EMPLOYER, TO
INVESTIGATE MY CLAIM, AND TAKE ANY ACTION DEEMED NECESSARY TO RESOLVE THE CLAIM.
BAJO PENA DE PERJURIO, JURO O AFIRMO QUE LA INFORMACIÓN QUE HE DADO EN ESTE FORMULARIO DE RECLAMO ES VERDADERA Y PRECISA. AUTORIZÓ A LA
OFICINA DE SALARIOS Y HORAS DE TRABAJO DEL DEPARTAMENTO DE SERVICIOS DE EMPLEO (DOES, POR SUS SIGLAS EN INGLÉS)DEL DISTRITO DE COLUMBIA
PARA DIVULGAR CUALQUIER Y/O TODA LA INFORMACIÓN CONTENIDA EN MI ARCHIVO DE RECLAMO A MI EMPLEADOR, PARA INVESTIGAR MI RECLAMO Y TOMAR
LAS MEDIDAS QUE SE CONSIDEREN NECESARIAS PAR A RESOLVER EL RECLAMO.
SIGNATURE/ FIRMA: _____________________________________________________________________ DATE/FECHA: _____________________________
ORIGINAL SIGNATURE REQUIRED (ONLY ORIGINAL SIGNATURE ACCEPTED)/
FIRMA ORIGINAL REQUERIDA (SOLO LA FIRMA ORIGINAL SE ACEPTARA)
UNDER PENALTY OF PERJURY, I HEREBY CERTIFY THAT THE CLAIMANT NAMED ABOVE, WHO REQUIRES ASSISTANCE DUE TO DISABILITY OR INABILITY TO
READ OR WRITE, AUTHORIZED ME TO COMPLETE THIS WAGE PAYMENT CLAIM FORM FOR HIM/HER. IF THE CLAIMANT WAS UNABLE TO SIGN THIS
APPLICATION, I HAVE PRINTED MY NAME ON THE SIGNATORY LINE.
BAJO PENA DE PERJURIO, YO CERTIFICO QUE EL RECLAMANTE NOMBRADO ARRIBA, REQUIRIÓ ASISTENCIA A CAUSA DE INCAPACIDAD O INHABILIDAD DE LEER O
ESCRIBIR, ME AUTORIZÓ A COMPLETAR ESTE FORMULARIO DE RECLAMO PARA ÉL/ELLA. SI EL RECLAMANTE NO PUEDE FIRMAR ESTA SOLICITUD, YO HE
IMPRIMIDO MI NOMBRE EN LA LÍNEA ASIGNADA.
____________________________________________________ ___________________________________________________ DATE/FECHA: _______________________
SIGNATURE OF ASSISTANT/ FIRMA DEL ASISTENTE PRINT FULL NAME/IMPRIMA SU NOMBRE COMPLETO
MAIL THIS FORM ALONG WITH SUPPORTING DOCUMENTATION TO (COPIES ONLY)
ENVÍE ESTE FORMULARIO JUNTO CON LOS DOCUMENTOS DE RESPALDO POR CORREO REGULAR A (SOLO COPIAS):
D.C. DEPARTMENT OF EMPLOYMENT SERVICES
OFFICE OF WAGE-HOUR
4058 MINNESOTA AVENUE, NE, SUITE 3600 | WASHINGTON, D.C. 20019 | PHONE: (202) 671-1880 | FAX: (202) 673-6411
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D.C. OFFICE OF WAGE-HOUR: WAGE PAYMENT CLAIM FORM (Government of the District of Columbia)

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Completed 31 December 2021

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