LABOR COMMISSIONER, STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT
PLEASE PRINT OR TYPE ALL INFORMATION
Refer to the accompanying Guide to assist you in filling out this form.
☐ YES ☐ NO
1. Is your claim about a public works project? [If your answer is “YES,” STOP here, DO NOT FILL OUT THIS FORM, and fill out the “PW-1” claim
form instead. If your answer is “NO,” proceed with this form.]
2. Have you filed a retaliation complaint against your employer with the Labor Commissioner?
☐YES, on: _________/________/________ ☐ NO [ If you have been retaliated against, you may file a retaliation
Month Day Year complaint by filling out another form, “DLSE FORM 205.”]
3. Is there a union contract covering your employment?
☐YES [If “YES,” attach a copy of the Collective Bargaining Agreement.]
4. Are other employees also filing wage claims against your employer? ☐YES ☐NO ☐I DON’T KNOW
Part 1: LANGUAGE ASSISTANCE & REPRESENTATION
5a. Do you need an interpreter?
5b. If you checked “YES” to Box 5a, enter the language needed
6a. If you are being assisted with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME
6c. Your ADVOCATE’S MAILING ADDRESS (Number, Street, Floor, Suite)
12. Your MAILING ADDRESS (Street Number, Street Name, Apartment Number)
Part 3: CLAIM FILED AGAINST (EMPLOYER INFORMATION)
13. EMPLOYER / BUSINESS NAME(S)
14. EMPLOYER’S VEHICLE LICENSE PLATE #
16. ADDRESS of EMPLOYER / BUSINESS (Street Number, Street Name, Floor, Suite):
17. ADDRESS where you worked, if different from Box 16 (Number, Street, Floor, Suite):
18. NAME of PERSON IN CHARGE (First Name, Last Name)
19. JOB TITLE / POSITION of PERSON IN CHARGE
21. TYPE OF WORK PERFORMED
22. TOTAL NUMBER
23. EMPLOYER STILL IN BUSINESS?
☐YES ☐NO ☐DON’T KNOW
24. Check which box describes your employer, if you know: ☐CORPORATION ☐INDIVIDUAL ☐PARTNERSHIP ☐LLC ☐LLP
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012) (Page 1 of 3)