Vermont Department of Labor
Wage and Hour Program
P.O. Box 488
Montpelier, VT 05601-0488
Telephone: 802-828-0267Fax: 802-828-4198

Worker’s Information
Worker’s Name:
SS #
Telephone #
Worker’s Mailing Address:
Worker’s E-Mail Address:
Are you a High School Student?

Business Information
Business Name:
Business Telephone # :
Business Owner’s Name:
Job Title:
Business Mailing Address:
Physical Address:

Start Date:
Last Day Worked:
Still Employed ?
Rate of Pay $
per (hr., day, wk., yr.)
Claim for (check all that apply): Unpaid Wages
Unpaid Overtime
Improper Deduction
Unpaid Benefits

Indicate breakdown of unpaid wages and overtime below, for improper deductions or unpaid benefits, please provide details supporting your claim.

Pay Period ending date Date Payment was due * Number of Hours unpaid Amount Unpaid Total Amount of
Wages owed this
pay period.

Please explain your claim:

* can not be greater then 2 years old

I hereby certify that, to the best of my knowledge, these statements are true. I understand that a copy of this claim, and any materials that I submit to the Wage & Hour Program relative to this claim, will be forwarded to my employer and/or my employer's representative.