Fillable Information and Instructions (Office of the Chief Information Officer)

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Information and Instructions (Office of the Chief Information Officer)

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Wage Claim
Information and Instructions
The Wage Claim form must be completed with the necessary details to support your claim. If your claim
does not have the total unpaid wages, a completed wage claim, social security number and signature, it
will be returned.
Wage Claim Process
After your wage claim is received and accepted, we will ask the employer for information. We may contact
you for additional information. When the investigation is complete, we will determine whether your claim
is enforceable. If the claim is enforceable, we will inform the employer. If necessary we will take the wage
claim to small claims court and then attempt to collect on the judgement.
Vacation
You are only entitled to vacation pay if it is due under a policy or agreement with the employer.
Health benefits, profit sharing or pension plans
If your claim is for health benefits, profit sharing or pension plans, contact the U.S. Department of Labor at
www.dol.gov/agencies/ebsa
or 866-444-3272.
Overtime
If your claim is for failure to pay overtime contact the U.S. Department of Labor at
www.dol.gov/whd
or
515-284-4625.
Rejected Claims
We cannot accept a claim if:
the amount of money owed to you exceeds $5,000.00
the work was not done in Iowa
the work was done more than one year ago
If you are paid any or all of your wages from your employer after you have submitted your wage claim,
notify the Iowa Division of Labor within three days of payment.
Submit a completed wage claim and wage claim worksheet along with supporting documents (pay check
stubs, employer policy, timesheets, etc.).
By submitting a claim for wages, you grant exclusive control of your wage claim to the assigned
investigator.
Iowa Division of Labor
Wage Payment and Collection
150 Des Moines Street
Des Moines, IA 50319-0209
P
hone: 515-725-5619
Fax: 515-725-4123
www.iowawage.gov
w
age@iwd.iowa.gov
Equal Opportunity Employer/Program
Auxiliary aids and services are available upon request to individuals with disabilities.
For deaf and hard of hearing, use Relay 711.
Part 1 - Claimant Information
Mr. Ms.
First name
Middle name
Mailing address
City
State
Zip
Date of birth
Home phone
Cell phone
Email address
Part 2 – Who we can contact if you cannot be reached
First name
Last name
Phone number
Email address
Part 3 – Employer Information
Business name
Type of business
Phone number
Mailing address
City
State
Zip
Bank used for payroll
Address
City
State
Zip
The employer is still in the same business:
Yes No, explain:
Part 4 – Employment Agreement
I was hired by
Type of work performed
Direct supervisor
Supervisor phone number
Supervisor email address
Work performed was in Iowa:
. Yes No
Employment start date
Employment end date
My employer set my Yes
regular work hours: No
Pay agreement
Oral Contract (provide copy)
Rate of pay: $ Per: Hour Weekly Bi-weekly Monthly
Other:
Method of payment: Check Cash Other:
I was covered by a union contract: Yes No
If yes, contact your union representative before filing this claim
I signed authorization for other deductions: Yes No
If yes, explain:
Employer deducted social security and withholding taxes:
Yes No, explain:
Part 5 – Reason for leaving employment
I quit I was discharged I still work for this employer
Detail explanation:
Part 6 – Attorney
I have retained an attorney or filed a lawsuit regarding this matter: Yes No
If yes, contact your attorney before filing this claim and fill out the information below
Attorney name
Phone number
Email address
County where lawsuit is filed
I am willing to testify in court: Yes No, explain:
Page 1
04.06.2020
900-004
Wage Claim
FOR OFFICE USE ONLY
Claim #:
Investigator:
Claimant Social Security Number:
Iowa Division of Labor
150 Des Moines Street
Des Moines, IA 50309-1836
Phone: 515-725-5619
Fax: 515-725-4123
www.iowawag
e.gov
wage@iwd.iowa.gov
My claim is based on (if an amount is not due, put N/A for total):
Unpaid wages | salary – Total: $
Pay period dates
Hours worked
Rate of Pay
Amount owed
Amount Paid
Amount unpaid
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
Unpaid commissions – Total: $
Date
Total sales
Details
Amount unpaid
$
$
$
$
$
$
$
$
Employer’s agreement for time of pay:
Wage Claim Worksheet
Do not deduct taxes or social security.
Illegal deductions – Total: $
Pay period
Explanation
Amount deducted
$
$
$
$
Vacation | Personal time-off | Bonus – Total: $
Date
Reason
Amount unpaid
$
Other – Total: $
Date
Reason
Amount unpaid
$
$
$
$
Employer Name: Total Unpaid Wages: $
I certify that the information on this form and the attachments (if any) is true and accurate to the best of my knowledge.
I assign in trust this claim and all penalties accruing of non-payment, and liens securing them, to the Labor Commissioner. This assignment
shall become effective upon a determination by the Labor Commissioner that I have an enforceable claim. I authorize the Labor Commissioner
to settle this claim. I authorize the Labor Commissioner to receive payment for this claim, and authorize such payment to be mailed to me
unless I have made a different arrangement with the Labor Commissioner.
I understand that I must cooperate as required by the Labor Commissioner and it is my responsibility to provide sufficient information to prove
the claim due. I understand that there is no guarantee that the Labor Commissioner will accept my claim and collect on it.
Print Name Signature Date
Page 2
04.06.2020
900-004
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Information and Instructions (Office of the Chief Information Officer)

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Completed 13 August 2020

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