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Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

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  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
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      • All Public Meetings
      • Commission Meeting Agendas
      • Meeting Minutes
  • Divisions
    • Administration
      • Accounting
      • Human Resources, Special Services and MIS
      • Self-Insurance and Tax Office
    • Administrative Law Judge (ALJ) Division
    • ADOSH
      • Boiler Section
      • Elevator Section
      • Occupational Safety and Health (OSHA / ADOSH)
      • Research & Statistics (BLS)
    • Claims Division
    • Labor Department
    • Legal Division
    • Medical Resource Office (MRO)
    • Special Fund Division
  • News and Events
    • Public Notices
    • News and Events
  • Resources For
    • Resources for Employees
    • Resources for Employers
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  • EPST/Minimum Wage Retaliation Claim Form

EPST/Minimum Wage Retaliation Claim Form

Instructions

 

INSTRUCTIONS FOR FILING AN EPST/MINIMUM WAGE RETALIATION CLAIM

 

  • The EPST/Minimum Wage Retaliation Claim Form may be used only for allegations of discrimination or retaliation under Arizona’s earned paid sick time or minimum wage laws.  Do not use this form to report earned paid sick time violations related to accrual of earned paid sick time, noncompliance issues, usage of earned paid sick time, earned paid sick time payment disputes, or failure of an employer to post the required earned paid sick time notice in the workplace.  In addition, do not use this form to report discrimination or retaliation that is related to age, disability, equal pay/compensation, genetic information, national origin, pregnancy, race/color, religion, sex, or sexual harassment.  For more information about filing these type of claims, please visit the Equal Employment Opportunity Commission at https://www.eeoc.gov/index.cfm or the Arizona Civil Rights Division at https://www.azag.gov/civil-rights.
     
  • The EPST/Minimum Wage Retaliation Claim Form must be filled out as completely as possible, including all required fields.  Failure to provide required information may delay or result in dismissal of your claim. 
     
  • To avoid delay in processing a retaliation claim, the EPST/Minimum Wage Retaliation Claim Form must state the legal name of the claimant’s employer, as indicated on a paystub or tax form.  The claimant may submit a paystub, tax form, or other documentation to assist the Labor Department in identifying the correct employer
     
  • The EPST/Minimum Wage Retaliation Claim Form must be signed and dated by the claimant.  Electronic signatures will be accepted.
     
  • Please attach to your EPST/Minimum Wage Retaliation Claim Form copies of any documents or evidence supporting your claim.  Evidence of discrimination or retaliation may assist in the investigation process and expedite resolution of your Retaliation Complaint.    Please do not send originals of documents or evidence to the Labor Department.  The Labor Department is not responsible for the loss or damage of originals.
     
  • The completed EPST/Minimum Wage Retaliation Claim Form can be submitted: (1) Electronically by completing the Sign and Submit Form below; (2) by e-mail to [email protected]; (3) by Fax to (602)-542-8097; or (4) by U.S. Mail to Labor Department, P.O. Box 19070, Phoenix, AZ 85005-9070.
     
  • An EPST/Minimum Wage Retaliation Claim Form must be filed within one year from the date the alleged violation occurred or the date the employee knew or should have known of the alleged violation.  Claims pertaining to violations outside of this one-year period will be dismissed.
     
  • You must notify the Labor Department immediately if you move or change your address, e-mail address, or telephone number. 

Sign and Submit Form

Sign and Submit Form

Printer-Friendly Form

PDF icon Labor_3307 EPST_Minimum Wage Retaliation Claim Form.pdf

Related Forms

Unpaid Wage Claim Form
Minimum Wage Claim Form
Earned Paid Sick Time Claim Form
EPST/Minimum Wage Retaliation Claim Form
Youth Labor Complaint Form
Payment Compliance Complaint Form

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800 W. Washington Street
Phoenix AZ 85007
602-542-4661

 

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Tucson AZ 85716
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