California Wage Claim Form (DLSE Form 1): Fill It Out Free

Which form, and the first questions

The Labor Commissioner publishes this form in English and in Spanish. Both are official and can be filed. Choose the one you want; your answers go into it exactly as you type them.

Help with this step

The forms page lists the claim form and instructions in English, Spanish and other languages: Wage claim forms. The form says: if your claim is about a public works project, do not fill out this form; fill out the “PW-1” claim form instead (public works complaints). If you were retaliated against, the form says you may file a retaliation complaint with another form (retaliation complaints). DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

Which official form do you want to fill out? (required)

English form: “Initial Report or Claim”Official Spanish form: “Informe o Reclamo Inicial”

Preliminary questions

Item 1 on the form: “Is your claim about a public works project? If your answer is “YES,” STOP HERE. DO NOT FILL OUT THIS FORM. Fill out the “PW-1” claim form instead. If your answer is “NO,” proceed with this form.” Item 1 has no box to check.

IS THIS CLAIM RELATED TO YOUR EMPLOYER’S WRONGFUL CLASSIFICATION OF YOU AS AN INDEPENDENT CONTRACTOR INSTEAD OF AN EMPLOYEE?

YESNO

2. Have you filed a retaliation complaint against your employer with the Labor Commissioner?

YESNO

3. Is there a Union contract covering your employment?

YESNO

4. Are other employees also filing wage claims against your employer?

YESNOI DON’T KNOW

Language help and representation

Part 1 of the form, items 5 and 6.

Help with this step

DLSE’s guide says: check “YES” to item 5 if your primary language is not English and you want an interpreter, and enter the language. Item 6 is only for a lawyer or other advocate who is helping you with the claim; the guide says DLSE will mail copies of information about your claim to the advocate’s address. DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

5. Do you need an interpreter?

YESNO

A lawyer or other advocate is helping me with this claim (item 6)

Your information

Part 2 of the form, items 7 to 14.

Help with this step

DLSE’s guide says it will mail copies of information about your claim to the mailing address you enter, and that you must tell DLSE right away if your mailing address changes. The other phone can be, for example, a cell phone you use. DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

7. Your first name (required)

8. Your last name (required)

9. Home phone

10. Cellphone

11. Birth date

12. Your email address

13. Alternate contact: name and relationship

13a. Alternate contact phone

13b. Email of alternate contact

14. Your mailing address (street number, street name, apartment number) (required)

City (required)

State (required)

Zip code (required)

Your employer

Part 3 of the form, items 15 to 26: who the claim is filed against.

Help with this step

DLSE’s guide says: enter the complete name of your employer to the best of your knowledge, and every business name you know, including a “doing business as” (DBA) name. Enter the last known address of the employer; the address where you worked goes in item 20 if it is different. The person in charge can be the owner, your supervisor, a manager or another person who ran the business or oversaw your work. DLSE’s How to File page says the company name is often on pay stubs, mailing labels or product labels, and that if you cannot find it you can write down the vehicle license plate number of the person who pays you (dir.ca.gov). DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

15. Employer / business name(s) (required)

16. Employer’s vehicle license plate #

17. Employer phone

18. Employer’s email address

19. Address of employer / business (street number, street name, floor, suite)

City

State

Zip code

20. Address where you worked, if different from box 19 (number, street, floor, suite)

City

State

Zip code

21. Name of person in charge (first name, last name)

21a. Job title / position of person in charge

22. Type of business

23. Type of work you performed

24. Total # of employees

25. Employer still in business?

YESNOI DON’T KNOW

Final wages and bounced checks

Part 4 of the form, items 27 to 29a.

Help with this step

DLSE’s guide says: in item 28 show whether you still work for the employer, quit (with the date), were discharged (with the date), or another situation applies, briefly specified, for example “on disability leave”. In items 28b and 28c check “YES” if you have received your final paycheck including all wages owed, and enter the date you received it. Item 29a: check “YES” if any paycheck could not be cashed because the employer had no account with the bank or not enough money in it. DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

27. Date of hire

28. Check which box applies to you:

On the Spanish form “Todavía trabajo para el empleador” has no box: if you choose it, mark it by hand. On the English form “Other (specify)” has no box, only the line.

Still working for employerQUIT onDISCHARGED onOther (specify):

29. How were your wages paid?

BY CHECKBY CASHBY BOTH CASH & CHECKOTHER:

29a. If paid by check, did any of your pay checks “bounce”? For example, a paycheck could not be cashed because your employer had insufficient funds.

YESNO

Hours you typically worked

Part 5 of the form, items 30 and 31.

Help with this step

DLSE’s guide says: “DAY 1” is the first day of your workweek. If you do not know your workweek and your employer did not set one, DLSE uses the calendar week from 12:01 a.m. Sunday to midnight Saturday, so Day 1 would be Sunday. For each day you worked in your typical week, enter the times you usually started and stopped and check “am” or “pm”. Meal periods: only an uninterrupted meal period of at least 30 minutes in which you were relieved of all duty. Split shift example from the guide: shifts from 8 am to 12 pm and from 5 pm to 9 pm: 1st shift ended at 12 pm, 2nd shift started at 5 pm. If your hours were irregular, DLSE asks for the computation worksheet DLSE Form 55 (Excel) instead. DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

30. Check which box applies:

My work hours and days of work were usually the same each week that I worked.My work hours and/or days of work varied per week or were irregular. If you checked this box and you are claiming unpaid wages or meal and rest period violations, you should also fill out and submit the DLSE FORM 55.

Payment of wages

Part 6 of the form, items 32 to 35.

Help with this step

DLSE’s guide says: item 32: check “YES” if you were paid or promised a fixed amount regardless of the hours you worked, then enter how much you were actually paid and how often; if you were promised a different amount, enter that too. Item 33a: check “YES” if you were paid by the hour, and enter what you were actually paid per hour and, if different, what you were promised. Item 33b: if you were paid or promised different hourly rates, check “YES” and briefly describe it; the guide’s example: “Paid $10 per hour for 30 hours unloading truck, and $8 per hour for 15 hours checking inventory.” DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

32. Were you paid or promised a FIXED amount in wages per pay period, no matter how many hours you worked (for example, $400 per week, regardless of how many hours you worked)?

YESNO

33a. Were you an HOURLY employee?

YESNO

34. Were you paid by PIECE RATE?

YESNO

35. Were you paid by COMMISSION?

YESNO

Wages, compensation and penalties owed

Part 7 of the form, items 36 and 37. Check every claim that applies and fill in its claim period and amount. The form says the amounts are your best estimates at this time.

Help with this step

DLSE’s guide says: for claims marked *** attach a separate computation form: for commissions the Commission Summary (DLSE 155), for vacation pay the Vacation Pay Schedule. For business expenses DLSE’s page asks for the Schedule of Expenses. Subtotal: add all amounts earned/claimed. Total amount paid: what the employer paid you for these claims (gross). Grand total: subtotal minus total amount paid. The guide explains item 37: waiting time penalties (Labor Code §203) can apply if you were discharged or quit and the employer willfully did not pay your final wages on time; bounced-check penalties (§203.1) if a paycheck could not be cashed and you tried to cash it within 30 days. DLSE’s own guide: Instructions for filing a wage claim and guide to the form (PDF). How to file a wage claim (dir.ca.gov).

36. Claims (check all boxes below that apply)

REGULAR WAGES (for non-overtime hours)

OVERTIME WAGES (including double time)

MEAL PERIOD WAGES

REST PERIOD WAGES

SPLIT SHIFT PREMIUM

REPORTING TIME PAY

COMMISSIONS ***

VACATION WAGES ***

BUSINESS EXPENSES

UNLAWFUL DEDUCTIONS

PAID SICK LEAVE

PAID SICK LEAVE Supplemental Paid Sick Leave

OTHER [provide separate explanation]

Totals

Enter subtotal (add all amounts earned/claimed) $

Enter total amount paid $

Grand total owed [subtotal minus total amount paid] $

37. Check box(es) if you are claiming:

Waiting time penalties [Labor Code §203]

Penalties for “bounced” checks (checks issued with insufficient funds) [Labor Code §203.1]

Penalties for late payment wages [Labor Code §210]

Liquidated damages for late payment wages [Labor Code §1194.2]

Compensatory damages for willful misclassification [Labor Code §226.8]

Your name and date

The name line at the top of page 2 and the signature area on page 3. You sign by hand after you print.

Help with this step

The form says above the signature: “The amounts claimed are based on my best estimates at this time and may be adjusted based on further information or based on assistance with my claim provided by DLSE.” Read every page before you sign.

The form says: “The amounts claimed are based on my best estimates at this time and may be adjusted based on further information or based on assistance with my claim provided by DLSE.”

Print your name (top of page 2) (required)

Print name (under the signature, page 3) (required)

Date (optional: or write it by hand when you sign)

Check and download

Check every line. This is exactly what will be printed on the form. To change something, go back to that step.

Do this by hand after you print:

On the Spanish form, mark “Todavía trabajo para el empleador” (item 28) by hand: it has no box.
Attach a copy of the union contract / Collective Bargaining Agreement (item 3).
Item 30: the form says to also fill out and submit DLSE Form 55 if you are claiming unpaid wages or meal and rest period violations.
Commissions (***): attach the Commission Summary (DLSE 155).
Vacation wages (***): attach the Vacation Pay Schedule.
Business expenses: DLSE asks for the Schedule of Expenses (or your own list with the same information).
Other claim: the form asks for a separate explanation.
Sign page 3 by hand (Signed:).

The PDF is made in your browser. Nothing is sent to the Labor Commissioner.

Fill out the California wage claim form yourself

Which form, and the first questions

Preliminary questions

Language help and representation

Your information

Your employer

Final wages and bounced checks

Hours you typically worked

Payment of wages

Wages, compensation and penalties owed

36. Claims (check all boxes below that apply)

Totals

37. Check box(es) if you are claiming:

Your name and date

Check and download

Do this by hand after you print:

Your wage claim form is ready. What to do next

Do this by hand after you print:

Good to know