Unpaid Wage Claim Form


Instructions for Filing an Unpaid Wage Claim

  • The Unpaid Wage Claim Form is used for unpaid wages, bonuses, vacation, mileage, insufficient funds (NSF) checks, and unauthorized deductions from wages.  Do not use the Unpaid Wage Claim Form for minimum wage complaints, earned paid sick time violations, or retaliation claims.
  • The The Unpaid Wage 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 wage claim, the Unpaid 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 other documentation to assist the Labor Department in identifying the correct employer.
  • An Unpaid Wage Claim Form must be signed and dated by the claimant.  Electronic signatures will be accepted.
  • Please attach to your Unpaid Wage Claim Form copies of any documents or evidence supporting your claim, such as evidence of hours worked, rate of pay, and wages paid by your employer.  Evidence showing that wages have not been paid may assist in the investigation process and expedite resolution of your Unpaid 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 original documents.
  • The completed Unpaid 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.
  • Please note that a copy of the Unpaid Wage Claim Form and any evidence submitted to the Labor Department will be sent to the employer for a response.  The Labor Department cannot keep your Unpaid Wage Claim or supporting evidence confidential.
  • The amount of unpaid wages filed with the ICA Labor Department may not exceed $5,000.00.  If you are owed more than $5,000.00 in unpaid wages, you must file a claim with the U.S. Department of Labor, Wage and Hour Division or pursue a civil claim against your employer.
  • An Unpaid Wage Claim must be filed within 1 year from the date of accrual of the claim.  Claims pertaining to wages that accrued over 1 year ago will be dismissed.
  • If you have filed a civil lawsuit against your employer or your employer has filed for bankruptcy, the Labor Department will dismiss your Unpaid Wage Claim.  For questions about whether your employer has filed bankruptcy, please contact the United States Bankruptcy Court, District of Arizona.
  • An Unpaid Wage Claim may not include overtime wages.  If you are claiming overtime wages, you must file your claim with the U.S. Department of Labor, Wage and Hour Division.  If you have questions about overtime violations, please contact the U.S. Department of Labor, Wage and Hour Division.


Adobe ESign Form