In the bustling state of New York, where the labor market is as diverse as its population, the Ls 425 form emerges as a crucial document for workers seeking unpaid wage supplements. Issued by the New York State Department of Labor Division of Labor Standards, this form serves as a formal claim that employees can submit when they haven't received the supplemental wages they're entitled to. These supplements could include, but are not limited to, holiday pay, vacation pay, sick pay, as well as health-related benefits. The process demands that all sections of the form be filled out with clarity and sent to the specified address in Albany, NY, ensuring that the claimant's grievances are properly registered for a formal review. Notably, the form also highlights that individuals earning more than $900 gross per week in certain roles are exempt from wage supplement coverage, underscoring the importance of understanding one’s eligibility before filing a claim. It stresses the necessity of having initially requested these supplements from the employer, signaling a preliminary step in seeking redress. This form, therefore, acts as a gateway for employees to navigate the complexities of labor law in New York, aiming to secure the benefits rightfully theirs while detailing the procedure for involving unions, if applicable, and encapsulating the specifics of the claimed supplements and the contractual or policy-based evidences supporting such claims.
| Question | Answer |
|---|---|
| Form Name | Form Ls 425 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | ls425 form, ny claim supplement form, ls425 fillable, wage supplement online |
New York State Department of Labor
Division of Labor Standards
Claim for Unpaid Wage Supplements
Answer all questions on both sides. Print clearly.
Send to: NYS Dept. of Labor,
Division of Labor Standards, Bldg. 12, Rm. 185C,
State Office Campus, Albany NY 12240
For office use only |
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Identification number
Refer to wage claim ID no., if any
Taken by
Section
Note: You must have asked for the supplements due before we can help you.
1. |
Your full name |
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3. |
Social Security number |
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Ms. |
Mrs. |
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Mr. |
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2. |
Your address |
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Apt. no. |
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City, town or village |
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County |
Zip code |
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4. |
(Area code) phone number |
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Day |
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Evening |
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5. |
Claim against (trade name of employer) |
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6. |
Corporation name, if any |
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7. |
Address of main office or headquarters of firm |
City, town or village |
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County |
Zip code |
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8. |
(Area code) phone number |
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9. Names and addresses of responsible persons of firm |
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10. |
Kind of business firm engaged in |
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Is the firm still in business? |
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Yes |
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No |
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12. |
What was your work or occupation with this firm? |
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13. Address where you worked |
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Zip code |
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14. |
Date hired |
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15. Name and position of person who hired you |
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Name of superintendent, manager or foreman |
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17. |
Latest agreed rate of pay |
18. Last day worked |
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Status with firm |
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20. Reason for quitting, discharge, or layoff |
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(per hour, per week, per day) |
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I quit |
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I was discharged |
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I was temporarily laid off |
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I am still employed |
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21. |
Were you a member of any union when |
If “Yes,” give name, local no., address, zip code and telephone no. of union |
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employed by this firm? |
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No |
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22. |
Have you asked your union for assistance? |
If “Yes,” what action has the union taken? |
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No |
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Before answering question 24, first fill out the back of this form to help you figure payments due |
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23. |
Name and address of employer’s bank |
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Zip code |
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24. Total amount of payment due |
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$ |
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25. |
Did you request these benefits? |
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26. |
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Date of request |
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27. |
To whom was the request made? |
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No |
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28. |
Did the employer refuse to pay these benefits? |
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If “Yes,” give employer’s reason for refusal |
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Yes |
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No |
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29. |
Were any payments due you paid by checks returned not honored? |
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30. How were wages paid? |
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Cash |
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Check |
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Other (explain) |
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Yes |
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No |
If “Yes,” submit photo copies of check(s) |
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Any false statements knowingly made are punishable as a Class A misdemeanor (Section 210.45, the New York State Penal Law). I affirm that the above statements are true.
I authorize the Commissioner of Labor, deputies or agents to receive, endorse my name on, and deposit in the account of the Commissioner of Labor any checks or money orders made out to me as payment on this claim.
Claimant’s signature |
Date |
See Reverse
LS 425 (08/13)
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31. |
Supplement claimed |
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32. Period involved |
33. Date payments due and payable |
34. |
Amount claimed |
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Holiday pay |
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Vacation pay |
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Sick pay |
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Health insurance |
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Hospital |
Medical - surgical |
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Bonus |
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Expenses |
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Other (specify) |
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35. |
Total amount |
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claimed $ |
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36. |
Did this employer previously pay this type of benefit to you? |
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Yes |
No |
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A. For what period? ______________________________ |
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Amount $ _________________________________ |
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B. Who paid the benefits? |
Employer |
Union |
Other (explain; e.g., Blue Cross, HIP) |
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37. What kind of agreement covers this benefit? If based upon a written document, attach a copy. |
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Company policy |
Oral |
Written (specify, e.g., employee handbook, letter) |
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Union contract |
Other (explain) |
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38. What are the terms of agreement (eligibility requirements) for this benefit?
39. Include any additional information below