DOL: Online Wage Claim Form

Question 1Are you claiming wages for work you performed within the last two years?

Directions for Wage Claim Completion & Disclaimer

Important, please read:
Based upon the answers you selected to the above questions, the Indiana Department of Labor may be able to accept your claim. Please complete all fields in the following form.
Incomplete wage claims will not be processed and will be returned to the claimant. Please complete each section of the Wage Claim Form in its entirety. Please also note that supporting documentation or evidence (timesheets, paystubs, employer policies, etc.) may be required to process your claim.

Disclaimer:
The Indiana Department of Labor has the right to reject this or any claim at any time if the claim is not valid or enforceable.

I have read and understand the information provided in the Directions and Disclaimer.

Company Address Where You Performed Work

Company Name:

PLEASE ENTER THE NAME OF THE COMPANY
Address:

PLEASE ENTER THE ADDRESS
City:

PLEASE ENTER THE CITY
State:
Zip:

PLEASE ENTER THE ZIP CODE
Phone:
() - Ext.
Is the company's corporate headquarter address the same as the address where you worked?

PLEASE ANSWER THE QUESTION: YES or NO

Employment History Disclaimer

I understand that this wage claim will be sent to my employer or former employer and that the Indiana law does not provide job protection for the person filing this claim. I also understand that I may not submit a wage claim for unpaid vacation time if I am still employed.

Employment HistoryLength of Employment:

From: Month Day Year
To: Month Day Year
Status of employment when filing this wage claim:
(If you are still presently employed by your employer, please select, still employed.)
Reason employer provided for nonpayment:

Why are you filing this claim?There are five general types of Wage Claims the Indiana Department of Labor may accept. Please indicate the type of Wage Claim you are filing. Please select all that may apply:

I didn't receive my final paycheck
I wasn't paid at least minimum wage
I wasn't paid overtime
I wasn't paid my vacation time (do not include bonus or sick time)
There was an improper or illegal deduction from my paycheck

How were you paid during the time period you submitted the Wage Claim? For Multiple payment types, please use the "Add Another Payment Type" Button below.

Please select how you were paid

Hourly/Salary
Wages Due From	Month Day Year
Wages Due To	Month Day Year
Hourly Rate of Pay	$(Ex. If you are paid $10.00 per hour, input 10.00)
Regular Hours Worked	Hours (Number of unpaid hours you worked and are claiming)
Overtime Rate of Pay	$(Hours worked greater than 40 in a single work week)
Overtime Hours Worked	Hours (Number (if any) of overtime hours you worked and are claiming)
Amount Owed	$(Total amount from this box only)

Hourly/Salary
Wages Due From	Month Day Year
Wages Due To	Month Day Year
Hourly Rate of Pay	$(Ex. If you are paid $10.00 per hour, input 10.00)
Regular Hours Worked	Hours (Number of unpaid hours you worked and are claiming)
Overtime Rate of Pay	$(Hours worked greater than 40 in a single work week)
Overtime Hours Worked	Hours (Number (if any) of overtime hours you worked and are claiming)
Amount Owed	$(Total amount from this box only)

Supporting Documentation & EvidenceSupporting documentation is required (time sheets/records, employer policies, etc.). For the timeliest service, the preferred method to submit supporting documentation is by emailing documents to wageclaims@dol.in.gov. Supporting documentation may also be sent by fax to (317) 234-4449 or by mail to the Indiana Department of Labor office located at:

Indiana Department of Labor
Attention: Wage Claim Specialist
402 West Washington Street, Room W195
Indianapolis, Indiana 46204

Submission of Supporting documentation is required within two weeks of the date this claim is submitted. Your wage claim will not be processed until the Indiana Department of Labor receives the supporting documentation. Please check items which you intend to provide as supporting documentation:
(Can select multiple boxes)

Copy of paycheck stub or earnings statement
Employer Policies
Timesheets or hours worked
Other, please specify
You selected "other", please specify:
None

Wage Claim Transmission

I hereby certify under the penalty of perjury that the above statements are true and that I will testify to the same before a court of law if necessary, to collect the amount due to me. Pursuant to Indiana Code 22-2-9-5, I hereby assign the Commissioner of Labor all my right, title and interest in and to the above certified claim for processing in accordance with the provisions of Indiana Code 22-2-9-1, et seq.

DOL > Wage & Hour > Online Wage Claim Form Online Wage Claim Form

Wage Claim Questions

Prefix:

First Name:

Middle Initial:

Last Name:

Suffix:

Street Address:

City:

State:

Zip:

Phone:

Email:

Company Name:

Address:

City:

State:

Zip:

Phone:

Company Name:

Address:

City:

State:

Zip:

Phone: