Form Ls 425 PDF Details

Every year, in the month of June, businesses and individuals have to file what is called a Form LS 425. This document is used to inform the state of your company's or personal income tax liability. The form must be filed by all business entities and self-employed individuals, regardless of whether or not they owe any taxes. So, if you're wondering whether or not you need to fill out this form, the answer is yes - every single business in Louisiana has to file it annually. If you're not sure how to go about doing that, keep reading! We'll walk you through everything you need to know.

QuestionAnswer
Form NameForm Ls 425
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesls425 form, ny claim supplement form, ls425 fillable, wage supplement online

Form Preview Example

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

S

 

Identification number

Refer to wage claim ID no., if any

Taken by

Section 198-c (3) of the New York State Labor Law excludes from wage supplement coverage those persons in an administrative, executive or professional capacity whose earnings exceed $900 gross per week

Note: You must have asked for the supplements due before we can help you.

1.

Your full name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Social Security number

 

Ms.

Mrs.

 

Mr.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Your address

 

 

Apt. no.

 

City, town or village

 

 

County

Zip code

 

 

4.

(Area code) phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Evening

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Claim against (trade name of employer)

 

 

 

 

 

 

 

6.

Corporation name, if any

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Address of main office or headquarters of firm

City, town or village

 

County

Zip code

 

 

8.

(Area code) phone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. Names and addresses of responsible persons of firm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Kind of business firm engaged in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

 

Is the firm still in business?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.

What was your work or occupation with this firm?

 

 

 

13. Address where you worked

 

 

 

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

Date hired

 

 

 

 

15. Name and position of person who hired you

 

16.

Name of superintendent, manager or foreman

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17.

Latest agreed rate of pay

18. Last day worked

19.

Status with firm

 

 

 

20. Reason for quitting, discharge, or layoff

 

(per hour, per week, per day)

 

 

 

 

 

 

 

I quit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I was discharged

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I was temporarily laid off

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am still employed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

Were you a member of any union when

If “Yes,” give name, local no., address, zip code and telephone no. of union

 

 

 

employed by this firm?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

Have you asked your union for assistance?

If “Yes,” what action has the union taken?

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Before answering question 24, first fill out the back of this form to help you figure payments due

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

Name and address of employer’s bank

 

 

 

 

 

 

 

Zip code

 

24. Total amount of payment due

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25.

Did you request these benefits?

 

26.

 

Date of request

 

 

 

27.

To whom was the request made?

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28.

Did the employer refuse to pay these benefits?

 

If “Yes,” give employer’s reason for refusal

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29.

Were any payments due you paid by checks returned not honored?

 

30. How were wages paid?

 

Cash

 

Check

 

Other (explain)

 

Yes

 

No

If “Yes,” submit photo copies of check(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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)

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31.

Supplement claimed

 

 

 

 

 

32. Period involved

33. Date payments due and payable

34.

Amount claimed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Holiday pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vacation pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sick pay

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health insurance

 

Hospital

Medical - surgical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bonus

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35.

Total amount

 

 

 

 

 

 

 

 

 

 

 

claimed $

 

 

 

 

 

 

 

 

 

 

36.

Did this employer previously pay this type of benefit to you?

 

Yes

No

 

 

 

 

 

 

A. For what period? ______________________________

 

Amount $ _________________________________

 

 

 

 

 

B. Who paid the benefits?

Employer

Union

Other (explain; e.g., Blue Cross, HIP)

 

 

 

 

 

 

 

 

 

37. What kind of agreement covers this benefit? If based upon a written document, attach a copy.

 

 

 

 

 

Company policy

Oral

Written (specify, e.g., employee handbook, letter)

 

 

 

 

 

 

Union contract

Other (explain)

 

 

 

 

 

 

 

 

 

38. What are the terms of agreement (eligibility requirements) for this benefit?

39. Include any additional information below