Minimum Wage Claim Form


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.


Adobe ESign Form