Wage Claim Form. Instructions for Completing the Wage Claim Form

Wage Claim Form Instructions for Completing the Wage Claim Form PLEASE NOTE THE FOLLOWING: 1. Asking and being denied wages from the employer prior to filing a claim would expedite the investigation process. 2. If you are a union member, under the law you MUST exhaust all union remedies first. If you have done this, please provide documentation showing all remedies have been exhausted. 3. Please note that the wages you are claiming MUST have been earned in the past two (2) years to file a claim with our office. If your wages were earned prior to this, you may file a claim in the appropriate court. However, please be aware that in order to file in court your wages must have been earned in the past three (3) years. Instructions: This form must be completed, SIGNED, and returned before we can investigate your claim. Please print or type your information. Fill it out completely and, if necessary, use a separate sheet of paper to provide additional information. Please keep a copy for your records. Attach copies of any documents which support your claim, such as an employment contract, wage agreement, commission statements, invoices, time records, list of hours worked, check stubs, written fringe benefit (vacation pay, sick pay, holiday pay, paid time off, bonus, expense reimbursement), policy or contract. Please note that if the claim form is not completely filled out and signed it will be returned. Also, please provide a phone number and an email address (if available) where you can be reached during the day. Acceptance of your claim will be acknowledged by a letter from this office. What to Expect from Employment Standards Service: Once we conduct an investigation, we will attempt to determine whether your claim is valid. If your employer denies that wages are owed, you have the opportunity to provide proof that your claim is valid. The investigation of your claim will be handled as quickly as possible. While we understand your desire to have your claim resolved immediately, please refrain from calling for the status of your claim as this only delays the time to resolve claims. When a final determination has been made, you will be immediately notified in writing. Should you have additional information once you have filed your claim, please mail or fax the information to the attention of the investigator assigned to your claim. This information can be found on your claim acknowledgement letter from this office. Your claim will remain in the open status until a final determination is made by our office. Please note that once your claim has been closed, it cannot be reopened. Once your form has been completed please mail it, along with any pertinent back-up documentation to the address below. Examples of Work Hourly An hourly employee is paid based on an hourly amount. Hourly employees do not have a contract, and are only paid for hours worked. The employer determined the hours for an hourly employee each week. Hourly employees must document their work by using a time card system or completing a time sheet. Salaried A salaried employee is paid based on an annual amount, called a salary. This salary is divided between the pay periods (as determined by the company) for the year. Some salaried employees are given an employment contract. Salaried employees are not required to sign a time sheet or otherwise to account for their time unless required by the employer. They get paid non on hours worked, but on that overall salary, so if a salaried employee works more or less than a normal 40-hour work week that is not documented by the employer. Department of Labor, Licensing and Regulation Division of Labor and Industry Employment Standards Service 1100 North Eutaw Street, Room 607 Baltimore, MD 21201 Telephone Number: (410) 767-2357 Fax Number: (410) 333-7303 E-mail: mailto:dldliemploymentstandards-dllr@maryland.gov Rev. 11/2015

Wage Claim Form For Office Use Only: Reference PLEASE NOTE THE FOLLOWING: 1. If you have not requested your wages from your employer, you MUST have asked and been denied wages before we are able to help you. 2. If you are a union member, under the law you MUST exhaust all union remedies first. If you have done this, please provide documentation showing all remedies have been exhausted. 3. Please note that the wages you are claiming MUST have been earned in the past two (2) years to file a claim with our office. If your wages were earned prior to this, you may file a claim in the appropriate court. In order to file in court your wages must have been earned in the past three (3) years. Claim YOU MAY NOT FILE A WAGE CLAIM AT THIS TIME IF ANY OF THE FOLLOWING APPLIES TO YOU: 1. I am being represented by an attorney in this matter. 2. My claim is under consideration by grievance, arbitration, government agency or by another state. 3. I filed a case against this employer for unpaid wages in court. 4. I am an owner or partner in this business. 5. If 50% or more of your work performed for the wages you are claiming are outside of Maryland. SECTION A. Personal Information This form and any documentation supporting your claim will be sent to the employer for their reply. Name: SSN: - - First Middle Initial Last Address: Street City State Zip Code Birthdate: Daytime Telephone: Email Address: Gender: Male Female Race (please choose all that apply): American Indian or Alaska Native Asian Black/African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White SECTION B. Employment Information Employer or Company Name: Telephone: Employer s Address: Street City State Zip Code Owner s Name: Supervisor s Name: Type of Business: (Example: retail, restaurant, construction, etc.) My Job Position: (Example: office worker, carpenter, etc.) My first day of work was: My last day of work was Next scheduled payday is: Page 1 of 3

I was/am: Fired Laid-Off Quit Other I am still working there number of days per week. My rate of pay was/is: $ per: Day Hour Month Year Commission Frequency of pay: I am paid: Daily ly Bi-ly Monthly Bi-Monthly Please indicate exact address where work was performed and, if possible, including county: Check here if work was performed in various locations throughout Maryland. SECTION C. Type of Wages and Dollar Amount Owed Failure to complete this section will result in your claim being returned to you. For examples of hourly and salary work, see Instructions Page. Yes No Questions Were you hired as an independent contractor for the work performed on this claim? Did your employer deduct federal taxes, state taxes, FICA? If yes, send a copy of your pay stub. One Type(s) of Wages Due Reference and/or Instruction Number of Hours/Days you are Claiming Rate of Pay You are Claiming Period Claimed (Must be within 2 years with our office.) Begin Date End Date Hourly (Time calculated by hours) $ per hour Salaried (Time calculated by days) $ per year Piece Rate or Flat Rate Must Complete Section E $ per rate Commission Must Complete Section E % of Pay Overtime Deductions Unauthorized Must Provide Paystub Showing Deductions $ per hour $ per If claiming monies due for benefits, such as the Type(s) of Wages Due as indicated below, please attach a copy of the policy, manual or handbook, or if one is not available, provide a detailed explanation of the policy on a separate piece of paper. Leave: Personal Sick Vacation Other Holiday Expenses (employer bounced check fees) Other (Bonuses, Tips) Must Send Receipts Explain Page 2 of 3

SECTION D. Hourly Employee, Salary Employee, Minimum Wage, and Overtime Worksheet Only provide information for the hours worked each day you were not paid. May not exceed two (2) years. Salary employees must indicate each day that you worked. Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total Hours Worked 1 2 3 4 SECTION E. Commission, Bonus, Piece Rate, or Flat Rate Worksheet Attach a copy of the commission, bonus, piece rate, or flat rate agreement; or explain in detail how wages are earned. You must list each particular sale for which you have not been paid. Be specific and indicate how you arrived at the amount claimed. If you cannot provide a list, we must rely on the employer s records exclusively. Please use additional paper as needed. List sales or bonuses earned and not paid, or work completed for which you were Gross Amount Owed not paid. TOTAL Dollar Amount Owed $ SECTION F. Total Amount Claimed I am claiming a total of $ for this claim. I AUTHORIZE THE COMMISSIONER OF LABOR AND INDUSTRY OR A DESIGNEE TO RECEIVE, ENDORSE AND DEPOSIT ANY MONIES DUE TO ME AS PAYMENT IN THE ACCOUNT OF THE COMMISSIONER OF LABOR AND INDUSTRY. I UNDERSTAND THAT, IF A DETERMINATION HAS BEEN MADE IN MY FAVOR, ANY PAYMENTS COLLECTED ON BEHALF COULD BE REDUCED BY ANY MARYLAND DEBT I OWE, SUCH AS PAST-DUE CHILD SUPPORT, STATE INCOME TAXES, ETC. I understand that this form will be sent to the employer for his/her reply to the claim made above. I hereby certify that the above statements are true. Signature: (Original signature required, no photocopied signature accepted) Type or Print Name: Page 3 of 3

Wage Claim Authorization I,, have filed a claim for unpaid wages with the Department of Labor, Licensing, and Regulation, Division of Labor and Industry, Employment Standards Service (ESS) against my employer/former employer: Employer Name (and Trade Name, if applicable) Employer Address City State Zip Code I understand that my claim will be investigated by ESS and that after investigation, the Commissioner of Labor and Industry (Commissioner) will determine whether my employer/former employer has violated the Maryland Wage and Hour Law, Md. Code Ann., Lab. & Emp. Art. 3-401 et. seq. (MWHL) and/or Maryland Wage Payment and Collection Law, Md. Code Ann. Lab. & Emp. Art., 3-501 et. seq. (MWPCL). If the Commissioner determines the MWHL and/or the MWPCL have been violated, I hereby consent to the Commissioner resolving my wage claim: (1) informally through mediation; (2) if my claim is less than $3000, by issuing an administrative order directing my employer to pay my unpaid wages pursuant to MWPCL 3-507.1; or (3) by asking the Office of the Attorney General (OAG) to file a lawsuit on behalf of the Commissioner to my use and benefit in a Maryland court of competent jurisdiction pursuant to MWPCL 3-507 (a)(2) and (3) and (b). I understand the OAG is not required to file a lawsuit on behalf of the Commissioner to my use and benefit and may decline to accept the case. I understand that acceptance of my claim by ESS, the Commissioner, and the OAG does not guarantee collection of my unpaid wages. I understand that any administrative order issued by the Commissioner or any lawsuit filed by the OAG on behalf of the Commissioner to my use and benefit is limited to the collection of my unpaid wages as defined in the MWHL and/or MWPCL. I understand that in the event my employer files an action against me in any court of competent jurisdiction or other forum, neither the Commissioner nor the OAG will represent me in defense of that action and I will have to retain private counsel or represent myself. I understand I have the right to file a lawsuit against my employer/former employer for unpaid wages pursuant to the MWHL and/or the MWPCL with or without the assistance of a private attorney in a Maryland court without first filing a wage claim with ESS. I understand that if at any time after I file my wage claim with ESS, I retain private counsel to collect my wages, ESS, the Commissioner and/or the OAG will cease all actions on my behalf and close my case. I agree to cooperate fully with the ESS, the Commissioner, the Commissioner s designee, and the OAG in their investigation of my wage claim and during all phases of any administrative order issued by the Commissioner or any lawsuit filed by the OAG. I agree to notify ESS, the Commissioner, the Commissioner s designee, and/or the OAG immediately if my address or telephone number changes and/or if I receive payment in connection with my wage claim. I agree to promptly return all telephone calls and respond to all written correspondence received from ESS, the Commissioner, the Commissioner s designee, or the OAG. I agree to appear and participate in any settlement conference or mediation that is scheduled. If my employer/former employer appeals from an administrative order issued by the Commissioner directing my employer/former employer to pay me my wages, if requested I agree to appear and testify at any hearing scheduled before the Office of Administrative Hearings and/or before a court. If the OAG files a lawsuit on behalf of the Commissioner to my use and benefit to collect my unpaid wages, if requested I agree to appear and testify at any trial before the court.

In the event that I fail to cooperate fully with ESS, the Commissioner, the Commissioner s designee, and/or the OAG, I hereby authorize ESS, the Commissioner, the Commissioner s designee, and/or the OAG to take whatever action deemed appropriate, which may include ceasing an investigation, vacating or dismissing an administrative order issued by the Commissioner, or withdrawing from and/or dismissing a lawsuit filed on behalf of the Commissioner to my use and benefit (subject to the applicable Rules of Court). In the event the Commissioner and the OAG withdraw from a lawsuit, I agree that they will not be liable for any added costs associated with the prosecution of the suit. In the event of the dismissal of a lawsuit filed on behalf of the Commissioner to my use and benefit, I understand I may not be able to file a new lawsuit in my own name with or without the assistance of private counsel if the statute of limitations for filing such a lawsuit has run or if the court s dismissal of the case filed on behalf of the Commissioner to my use and benefit is with prejudice. I agree that ESS, the Commissioner, the Commissioner s designee, and/or the OAG may settle my wage claim for the amount I have claimed on my Wage Claim Form, the amount determined to be due and owing to me in any administrative order issued by the Commissioner, or the amount claimed due and owing to me in any lawsuit filed by the OAG on behalf of the Commissioner to my use and benefit, without prior notice to me or my prior approval. I understand any settlement of my claim may not include any additional damages a court may award at its discretion under MWPCL 3-507(b). I understand I will be notified of any settlement which would result in any compromise of the amount of my claim. I agree, however, that if I do not approve a settlement which would result in a compromise of my claim that is recommended by ESS, the Commissioner, the Commissioner s designee, and/or the OAG, the Commissioner and the OAG may withdraw from the case (subject to the applicable Rules of Court if a lawsuit has been filed). I hereby authorize the Commissioner or the Commissioner s designee to receive, endorse my name on, and deposit into the Commissioner s account or other appropriate account any checks or money orders made out to me as payment on my wage claim. I understand that I will then be issued a check from the State of Maryland representing the amount deposited. I understand, however, that the amount may be reduced by any outstanding State debt that I owe such as past due child support or state income taxes, etc. I understand that I am not responsible for the payment of any expenses incurred by the Commissioner in the prosecution of any action filed on my behalf to collect my wages, unless the expenses were: (a) approved by me in advance, or (b) mandated by statute or rule of court. I understand however that if the Commissioner and OAH withdraw from my case for any of the reasons noted above, I will be solely responsible for any added costs associated with the prosecution of the suit. I also understand that any judgment entered in my favor by a court of competent jurisdiction may be referred to the Maryland Department of Budget and Management s Central Collection Unit for collection and that if the Central Collection Unit is able to collect the judgment, the Central Collection Unit may deduct from the amount collected a fee of 17% to cover the expenses of collecting the judgment on my behalf. Date Signature of Wage Claimant Address City State Zip Code ( ) ( ) Telephone Number(s) Department of Labor, Licensing and Regulation Division of Labor and Industry Employment Standards Service 1100 North Eutaw Street, Room 607 Baltimore, MD 21201 Telephone Number: (410) 767-2357 Fax Number: (410) 333-7303 E-mail: mailto:dldliemploymentstandards-dllr@maryland.gov