State of Rhode Island and Providence Plantations
Rhode Island Department of Labor and Training
1511 Pontiac Avenue. P.O. Box 20390
Cranston, RI 02920-0944
Complete both sides of this form, sign and return to the address above; do not fax or email. Type or print clearly.
Incomplete forms will be returned. Complete ALL items to the best of your knowledge. Enclose any copies of
documentation that may be relevant to your claim. Please notify this oce immediately by mail if you have a change
of address, phone number or have been paid.
1. First and Last Name: ______________________________________________________________________________
2. Last 4 Digits of your Social Security #: ________
3. Address (Number & Street): _________________________________________________________________________
City/Town: _______________________________________________ State: _______________ Zip Code: ___________
4. Home phone: _________________ 5. Cell phone: ________________ 6. Email: _______________________________
7. Title/Occupation or Type of Work Done: _______________________________________________________________
EMPLOYMENT INFORMATION: (complaint will not be accepted unless this section is completed.)
8. Business Name: _________________________________________________ 9. Business Phone: _________________
10. Business Address (Number & Street, NOT P O Box): _____________________________________________________
Business City/Town: __________________________________________ State: __________ Zip Code: ____________
11. Other Business Name (s) that might be used by employer: ______________________________________________
12. Name of Person In Charge: __________________________________13. Title: _______________________________
14. Did you work at business address listed above? Yes No
If no, please provide the location where you did work: _________________________________________________
15. Hours per week: ____________ 16. Wage Rate: ____________
17. Type of Wage: Hourly Salary Commission Other, please explain: _____________________
18. Date hired: _________________________ 19. Date of separation: _________________________
20. Reason for separation (layo, quit, etc): _____________________________________________________________
21. Are you represented by an attorney? Yes No
If yes, please provide the attorneys name: ___________________________________________________________
22. Please check all the reason(s) why you are ling this claim:
Final paycheck not received Commission not received/incorrect
Vacation pay upon termination* Minimum wage
No paystub Sunday or holiday premium pay
Improperly classied as an Bounced paycheck
Paid Sick/Safe Leave
Overtime wages
Minimum shift
Illegal deductions
Independent Contractor
* If checked, please provide a written copy of the vacation policy
Case Number: _______________________
Date Received: _______________________
Dated Closed: ________________________
Examiner: ___________________________
Page 1 of 2
23. Did you ask the employer for the money you believe is due? Yes No
If yes, who did you ask? Name: ___________________________________________________________________
Title: _____________________________________________________________________
If no, why not (please provide the reason(s) for not asking; be specic)?
24. Do you have a signed employment contract or independent contractor agreement? Yes No
If yes, please provide a copy with this claim form.
25. List the dates and hours for which you believe wages are due, and the amount you are claiming. Attach additional
sheets if necessary and provide any relevant documentation to your claim.
Total Amount Claimed: $ _________________________
I hereby certify that to the best of my knowledge and belief that this is a true statement of the facts relating
to my complaint. I hereby assign all wages and penalties accruing because of their non-payment, and all liens
securing them to the Rhode Island Director of Labor and Training to collect in accordance with the law.
Signature: _______________________________________________ Date: __________________
Print Name: ______________________________________________
Minor child requires parent’s signature: ______________________________________________
IMPORTANT: This Division has jurisdiction over wage issues only. We cannot assist you in obtaining payment
for time not worked, or for expenses, tax issues, pension plan issues or unemployment.
DLT is an equal opportunity employer/program - auxiliary aids and services available upon request. TTY via RI Relay: 711
Page 2 of 2 Rev. 0618