Non-Payment Of Wages Complaint Form Page 2
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23. Did you ask the employer for the money you believe is due?
Yes
No
If yes, who did you ask? Name: ___________________________________________________________________
Title: _____________________________________________________________________
If no, why not (please provide the reason(s) for not asking; be specific)?
24. Do you have a signed employment contract or independent contractor agreement?
Yes
No
If yes, please provide a copy with this claim form.
25. List the dates and hours for which you believe wages are due, and the amount you are claiming. Attach additional
sheets if necessary and provide any relevant documentation to your claim.
Total Amount Claimed: $ _________________________
I hereby certify that to the best of my knowledge and belief that this is a true statement of the facts relating
to my complaint. I hereby assign all wages and penalties accruing because of their non-payment, and all liens
securing them to the Rhode Island Director of Labor and Training to collect in accordance with the law.
Signature: _______________________________________________
Date: __________________
Print Name: ______________________________________________
Minor child requires parent’s signature: ______________________________________________
IMPORTANT: This Division has jurisdiction over wage issues only. We cannot assist you in obtaining payment
for time not worked, or for expenses, tax issues, pension plan issues or unemployment.
DLT is an equal opportunity employer/program - auxiliary aids and services available upon request. TTY via RI Relay: 711
Page 2 of 2 Rev. 0615
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