Wage Claim Form – Fill Out and Use This PDF

Write clearly in ink. Under CLAIMANT INFORMATION, mark English or Spanish after “I want TWC to send future correspondence in”, and enter First Name, Middle and Last Name.

Enter Address, Apt #, City, State and Zip.

Enter Date of Birth (MM/DD/YY) and Social Security # (Optional): Social Security Number is optional but failing to include it will delay processing of your claim.

Enter the Phone # where you can be reached during normal business hours and the Email Address.

Under INFORMATION ABOUT YOUR EMPLOYER, enter the Business Name (If incorporated), and the Owner's First Name and Owner's Last Name (If sole proprietor or partnership).

Enter the Owner's Business Address, Suite #, City, State and Zip.

Enter YOUR Work Location (Street Address, City, State, Zip), the Employer's Work Phone # and the Employer's E-mail or Web Address.

Under Please complete the following employment information, write 1. What work did you perform?

Enter the Beginning date of employment, then under Employment status with this employer mark Still employed or enter the Quit date or the Termination date, and write the Reason for separation. 2. Write When were your regularly scheduled paydays?

Write What was your rate of pay?

Enter What was the agreed work schedule? as Hrs. per day, Days per wk. If other, describe. 3. Mark Oral or Written (please attach a copy) for Was your compensation agreement. 4. Mark Yes or No: Were the claimed wages earned in Texas? If not, was the job contracted in Texas? Mark Yes or No. 5. Mark Yes, No or Don't Know: Were taxes deducted from your paycheck? 6. Mark Yes, No or Don't Know: Is the employer still in business? Write the employer's home address and phone number and the name and phone number of your supervisor during the period claimed.

Mark Yes, No or Don't Know for 7. Is the employer in bankruptcy? and mark Yes or No for Are you in bankruptcy?

Write If yes, what is the bankruptcy filing date? Chapter, Case No, Where filed, and What is the bankruptcy attorney’s name, address, and phone number?

If you are related to the employer, please state the relationship.

Write 9. Did the employer give a reason for not paying you? If so, explain.

Choose the type(s) of unpaid wages that best describe your claim, and write the amount of unpaid wages, listing the gross amount of wages due: Regular, Commissions, Fringe Benefits, Pay Deductions, Overtime, Unpaid Bonus, “Pay Below Minimum Wage” and TOTAL UNPAID WAGES CLAIMED.

You cannot file for recovery of any type of expenses or reimbursement, since expenses and reimbursements are not wages.

In the list Regular, Commissions, *Fringe Benefits, the only fringe benefits that can be claimed are vacation pay, holiday pay, severance, sick leave, parental leave, paid time off, or paid days off. These benefits cannot be claimed unless provided for in a written agreement or a written policy of the employer.

Write 11. What was the scheduled payday(s) for these claimed wages?

If claiming regular, overtime, and/or minimum wage, list the dates you worked for which you received no wages, From to; explain how you determined the amount claimed and provide a breakdown of the days and hours worked.

If available, attach a copy of timecards or timesheets. Use the chart provided on the Wage Claim attachment to provide a breakdown of the days and hours worked.

If claiming commissions or bonus, write the period in which the wages were earned, From to.

Mark Yes or No: Are you aware of any agreement to pay commissions or bonus after termination?

Please explain how you determined the amount due. If available attach information to support your claim, such as written agreement, sales records, check stubs, etc. Use the Wage Claim attachment (page 2) to provide a breakdown of commissions or bonus.

If claiming a covered fringe benefit, please explain which benefit(s) you are claiming and indicate how you determined the amount due. Please attach a copy of a written policy or agreement providing a payment after separation. Also attach evidence of the amount owed (hours left) such as check stubs or other documents.

If claiming deductions, mark Yes, No or Don't Know for: did you sign any authorization for deductions other than regular payroll taxes? If yes, please explain (attach a copy).

Mark Yes or No for: Are you aware of any agreement (such as arbitration, collective bargaining agreement, union contract, ERISA, Service Contract Act, etc.) that existed between you and the employer? If yes, please attach a copy.

Write 17. Additional Comments.

“To be considered valid, your Wage Claim must be completed below and signed as true under penalty of perjury.” Write My name is (First) (Middle) (Last), my date of birth is (month/day/year).

Write and my address is (Street), (City), (State), (Zip Code) and (Country).

Under “I declare under penalty of perjury that the foregoing is true and correct”, write Executed in, County, State of, on the day of, (Month) and (Year), and sign on the Declarant Signature line.

Regarding question #12 on the Wage Claim form, include a breakdown of the Hours Worked Per Week.

Your wage claim cannot be accepted if it is filed later than the 180th day after the date the unpaid wages were due to be paid.

Mail your completed wage claim to Texas Workforce Commission, Wage and Hour Department, 101 East 15th Street, Room 514, Austin, TX 78778-0001, or fax it to 512-322-2885.

Title 2, Chapter 61, Texas Labor Code, provides a penalty for wage claims brought in bad faith.

If you feel your rights under the Payday Law have been violated, you may file a wage claim. Your wage claim cannot be accepted if it is not filled out completely, legibly, and accurately (if there is insufficient information on the wage claim to contact the employer, your claim will be returned or dismissed). It cannot be accepted if it is not signed or without a completed declaration that the information is true, under penalty of perjury. It cannot be accepted if you are an “independent contractor” and not an “employee” of the business (if you are unsure, file a claim and it will be determined if you were an independent contractor or an employee). It cannot be accepted if you were employed by a close relative (such as: mother, grandfather, or father-in-law) (if you are unsure, file a claim and the circumstances will be reviewed). It cannot be accepted if your employer filed for bankruptcy (if you are unsure, file a claim but you may also need to file proof of claim directly with the Bankruptcy Court). It cannot be accepted if you were employed by the federal government, the state, or a political subdivision of the state. It cannot be accepted if your wages are subject to a binding arbitration or collective bargaining agreement or contract (if you are unsure, file a claim and include the agreement or contract and the circumstances will be reviewed). It cannot be accepted if it is for subsequent pay periods: you can amend this claim prior to a preliminary wage determination order; do not file another wage claim. It cannot be accepted if you file against more than one employer on one claim form for a different pay period. It cannot be accepted if it is not for wages but for expenses, reimbursements or automobile allowances.