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.
Question | Answer |
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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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16. |
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? |
Yes |
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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Yes |
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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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Yes |
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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