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LABOR COMMISSIONER, STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT
FOR OFFICE USE ONLY
Initial Report or Claim
Taken by:
Taken by: Office:
Case #:
PLEASE PRINT OR TYPE ALL INFORMATION
Refer to the accompanying Guide to assist you in filling out this form.
Taken by: Date filed:
RCI Complaint:
☐ YES ☐ NO
Action:
PRELIMINARY QUESTIONS
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.]
☐NO
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?
☐YES ☐NO
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
and ORGANIZATION
6b. ADVOCATE’S PHONE
( )
6c. Your ADVOCATE’S MAILING ADDRESS (Number, Street, Floor, Suite)
CITY
STATE
ZIP CODE
Part 2: YOUR INFORMATION
7. Your FIRST NAME
8. Your LAST NAME
9. HOME PHONE
( )
10. OTHER PHONE
( )
11. BIRTH DATE
12. Your MAILING ADDRESS (Street Number, Street Name, Apartment Number)
CITY
STATE
ZIP CODE
Part 3: CLAIM FILED AGAINST (EMPLOYER INFORMATION)
13. EMPLOYER / BUSINESS NAME(S)
14. EMPLOYER’S VEHICLE LICENSE PLATE #
15. EMPLOYER PHONE
( )
16. ADDRESS of EMPLOYER / BUSINESS (Street Number, Street Name, Floor, Suite):
CITY
STATE
ZIP CODE
17. ADDRESS where you worked, if different from Box 16 (Number, Street, Floor, Suite):
CITY
STATE
ZIP CODE
18. NAME of PERSON IN CHARGE (First Name, Last Name)
19. JOB TITLE / POSITION of PERSON IN CHARGE
20. TYPE OF BUSINESS
22. TOTAL NUMBER
OF EMPLOYEES
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)
CLEAR
PRINT
PRINT YOUR NAME: ________________________________________
Part 4: FINAL WAGES / BOUNCED CHECKS
25. DATE OF HIRE
____/____/_____
Month Day Year
26. Check which box applies to you:
☐Still working for employer ☐QUIT on ___ /___/____ ☐DISCHARGED on ___/___/____
Month Day Year Month Day Year
☐Other (specify): _____________________________________________________________________________________
27a. If you QUIT, did you give 72
hours notice before quitting?
☐YES
☐NO
27b. If you QUIT, have you received your final payment of wages including all wages owed?
☐YES, on: _______ /_______/_________
Month Day Year
☐NO
28. If you were DISCHARGED, have you received your final payment of wages including all wages owed?
☐YES, on: _______ /_______/_________
Month Day Year
☐NO
29a. How were your wages paid?
☐BY CHECK ☐BY CASH☐BY BOTH CASH & CHECK
☐OTHER: __________________________________________
29b. If paid by check, did any of your paychecks “bounce”
(for example, paycheck could not be cashed because
employer has insufficient funds)?
☐YES ☐NO
Part 5: HOURS YOU TYPICALLY WORKED
30. Check which box applies: ☐My work hours and days of work were usually the same each week that I worked.
☐My work hours and/or days of work varied per week or were irregular. If you checked this box
and you are claiming unpaid wages or meal and rest period violations, you should also fill
out and submit the DLSE FORM 55.
31. If your work hours and days of work were usually the same each week, give your BEST ESTIMATE below of the hours you
usually worked and any time you took for a duty-free meal period during your TYPICAL workweek. DO NOT fill this out if
your work hours were too irregular to estimate a typical or average workweek (instead fill out the DLSE Form 55).
TIME WORK
STARTED
TIME WORK
ENDED
1st MEAL
START TIME
(if applicable)
1st MEAL
END TIME
(if applicable)
2nd MEAL
START TIME
(if applicable)
2nd MEAL
END TIME
(if applicable)
ONLY IF YOU WORKED A
SPLIT SHIFT:
DAY 1
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DAY 2
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DAY 3
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DAY 4
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DAY 5
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DAY 6
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DAY 7
of your
workweek:
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
☐am
_______☐pm
1st shift ended at 
☐am
_______ ☐pm
2nd shift started at
☐am
_______ ☐pm
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012) (CONTINUED – Page 2 of 3)
Part 6: PAYMENT OF WAGES
32. Were you paid or promised a FIXED amount of wages per pay period, no matter how many hours you worked (for
example, $400 per week, regardless of how many hours you worked)?
 ☐YES: I was paid $ ___________________ per ☐day ☐week ☐every 2 weeks ☐month ☐semi-monthly
☐other (specify):__________________________________________________
I was promised $ _____________ per ☐day ☐week ☐every 2 weeks ☐month ☐semi-monthly
☐other (specify):__________________________________________________
☐NO
33a. Were you an HOURLY employee?
☐YES: I was paid $______________ per hour.
I was promised $ _____________ per hour.
☐NO
33b. If you were an HOURLY employee, were you paid or promised more
than one hourly rate (based on the hours you worked or different job
tasks)?
☐YES (describe):
☐NO
34. Were you paid by PIECE RATE? ☐YES ☐NO
35. Were you paid by COMMISSION? ☐YES ☐NO
Part 7: WAGES, COMPENSATION & PENALTIES OWED
36. CLAIMS
(Check all boxes below that apply)
CLAIM PERIOD:
START DATE
(Month/ Day/ Year)
CLAIM PERIOD:
END DATE
(Month/ Day/ Year)
AMOUNT EARNED / CLAIMED
☐REGULAR WAGES (for non-overtime hours)
$
☐OVERTIME WAGES (including double time)
$
☐MEAL PERIOD WAGES
$
☐REST PERIOD WAGES
$
☐SPLIT SHIFT PREMIUM
$
☐REPORTING TIME PAY
$
☐COMMISSIONS ***
$
☐VACATION WAGES ***
$
☐BUSINESS EXPENSES
$
☐ UNLAWFUL DEDUCTIONS
$
☐OTHER (Specify):
$
ENTER SUBTOTAL (add all Amounts Earned/Claimed):
$
ENTER TOTAL AMOUNT PAID:
$
GRAND TOTAL OWED [Subtotal minus Total Amount Paid]:
$
*** Additional DLSE form should be submitted if you are making this claim. See “Instructions for Filing a Wage Claim.”
37. Check box(es) if you are claiming: ☐Waiting time penalties [Labor Code §203]
☐Penalties for “bounced” checks (checks issued with insufficient funds) [Labor Code §203.1]
I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection. The amounts claimed are based on my
best estimates at this time and may be adjusted based on further information, or based on assistance with my claim provided by DLSE.
Signed: __________________________________________________ Date: ________________________________________________
Print Name: ______________________________________________
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012) (CONTINUED – Page 3 of 3)
DO NOT WRITE ON THIS SIDE – For Office Use Only
Claimant:
Against:
Interpreter Needed:
Action Number:
Address of Claimant:
Address of Defendant:
Docket Date
Date Closed
Phone No. of Claimant:
Phone No. of Defendant:
Name & Address of Advocate:
Phone No. of Advocate:
Address change of Claimant as of:
Address change of Defendant as of:
DATE(S) CLAIM RECEIVED
DATE BOFE COMPLAINT
FILED
(if applicable)
DATE RCI COMPLAINT
FILED
(if applicable)
RECORD OF RECEIPTS
RECORD OF PAYMENTS TO CLAIMANT
Date
Received
Check,
Cash, etc.
Receipt Number
Amount
Division Check
Number
Date Paid
Balance Due
Signature/Remarks
CONFERENCE: DATES
PEND: DATES
NOTES:
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Completed 30 March 2022

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