Skip to main content

Industrial Commission of Arizona

0
  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • 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
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
  • How Do I
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
Industrial Commission of Arizona Logo
Industrial Commission of Arizona
Protection of life, health, safety, and welfare of Arizona's workforce

Follow Industrial Commission of Arizona on:

Main menu

  • Home
  • Agency Information
    • About Us
    • Commissioners
    • Director's Office
    • Legislation
      • Arizona Statutes
      • Arizona Rules
    • Meetings
      • 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
    • Resources for Insurers
    • Resources for Medical Providers
    • Resources for ICA Community
  • How Do I
  • Online Services
    • Forms
    • Self Service Center
    • ICA Community
  • Payment Portal
  • OMBUDSMAN
  • Home
  • Minimum Wage Claim Form

Minimum Wage Claim Form

Instructions

 

INSTRUCTIONS FOR FILING A MINIMUM WAGE CLAIM

 

  • The Minimum Wage Claim Form is used for complaints related to wages that were paid below the current minimum wage.  Do not use the Minimum Wage Claim Form for any other issues, including unpaid wages, mileage, unauthorized deductions, vacation, or earned paid sick time violations.
  • The Minimum Wage Claim Form must be filled out as completely as possible.  Failure to provide complete information may delay or result in dismissal of your claim.
     
  • To avoid delay in processing a minimum wage claim, the Minimum Wage 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 documentation to assist the Labor Department in identifying the claimant’s employer.
  • A Minimum Wage Claim Form must be signed and dated by the claimant.  Electronic signatures will be accepted.
     
  • Please attach to your Minimum Wage Claim Form copies of any documents or evidence supporting your Minimum Wage Claim, such as evidence of hours worked, rate of pay, and wages paid by your employer.  Evidence showing that wages were paid below the current minimum wage may assist in the investigation process and expedite resolution of your Minimum Wage Claim.  Please do not send original documents or evidence to the Labor Department.  The Department is not responsible for the loss or damage of originals.
     
  • A completed Minimum Wage Claim Form may 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.
  • You must notify the Labor Department immediately if you move or change your address, e-mail address, or telephone number.
  • A Minimum Wage Claim must be filed within 1 year from the date the wages were due.  Claims pertaining to wages that were due over 1 year ago will be dismissed.

 

Sign and Submit Form

Minimum Wage Claim Form

Printer-Friendly Form

PDF icon Labor_3325 Minimum Wage 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

Official Website of the State of Arizona

phoenix map

Contact Us:

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

 

tucson map

Contact Us:

Tucson Office
2675 E. Broadway Blvd
Tucson AZ 85716
520-628-5188

 

 

Arizona State Seal

Footer Nav

  • Statewide Policies
  • Site Map
  • The Ombudsman-Citizens Aide helps citizens to resolve ongoing issues with State Agencies