DLSE Form 1 "Initial Report or Claim" - California

What Is DLSE Form 1?

This is a legal form that was released by the California Department of Industrial Relations - Division of Labor Standards Enforcement - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the California Department of Industrial Relations - Division of Labor Standards Enforcement;
  • Easy to use and ready to print;
  • Available in Chinese;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DLSE Form 1 by clicking the link below or browse more documents and templates provided by the California Department of Industrial Relations - Division of Labor Standards Enforcement.

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Download DLSE Form 1 "Initial Report or Claim" - California

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LABOR COMMISSIONER, STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT
Initial Report or Claim
FOR OFFICE USE ONLY
Taken by:
Taken by: Office:
Case #:
PLEASE PRINT OR TYPE ALL INFORMATION
Taken by:
Date filed:
SIC #:
Refer to the accompanying Guide to assist you in filling out this form.
RCI Complaint:
Action:
YES
NO
PRELIM IN ARY Q U ESTIO N S
1.
Is your claim about a public works project?
[If your answer is “YES,” STOP here, DO NOT FILL OUT THIS FORM, and fill out the “PW-1” claim
form instead. If your answer is “NO,” proceed with this form.]
2.
Have you filed a retaliation complaint against your employer with the Labor Commissioner?
YES, on: _________/________/________
NO [ If you have been retaliated against, you may file a retaliation
Month
Day
Year
complaint by filling out another form, “DLSE FORM 205.”]
3.
Is there a union contract covering your employment?
YES
[If “YES,” attach a copy of the Collective Bargaining Agreement.]
NO
4.
Are other employees also filing wage claims against your employer?
YES
NO
I DON’T KNOW
Part 1: LAN G U AG E ASSISTAN CE & REPRESEN TATIO N
5a
5b
. Do you need an interpreter?
. If you checked “YES” to Box 5a, enter the language needed
YES
NO
6a
6b
. If you are being assisted with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME
. ADVOCATE’S PHONE
and ORGANIZATION
(
)
6c
CITY
STATE
ZIP CODE
. Your ADVOCATE’S MAILING ADDRESS
(Number, Street, Floor, Suite)
Part 2: YO U R IN FO RM ATIO N
7
8
9
10
11
. Your FIRST NAME
. Your LAST NAME
. HOME PHONE
. OTHER PHONE
. BIRTH DATE
(
)
(
)
12
CITY
STATE
ZIP CODE
. Your MAILING ADDRESS
(Street Number, Street Name, Apartment Number)
Part 3: CLAIM FILED AG AIN ST (EM PLO YER IN FO RM ATIO N )
13
14
15
. EMPLOYER / BUSINESS NAME(S)
.
. EMPLOYER
PHONE
EMPLOYER’S VEHICLE LICENSE PLATE #
(
)
16
CITY
STATE
ZIP CODE
. ADDRESS of EMPLOYER / BUSINESS
(Street Number, Street Name, Floor, Suite):
17
CITY
STATE
ZIP CODE
. ADDRESS where you worked, if different from Box 16
(Number, Street, Floor, Suite):
18
19
. NAME of PERSON IN CHARGE
. JOB TITLE / POSITION of PERSON IN CHARGE
(First Name, Last Name)
20
21
22
23
.
.
.
.
TYPE OF BUSINESS
TYPE OF WORK PERFORMED
TOTAL NUMBER
EMPLOYER STILL IN BUSINESS?
OF EMPLOYEES
YES
NO
DON’T KNOW
24
. Check which box describes your employer, if you know: ☐CORPORATION
☐INDIVIDUAL
☐ PARTNERSHIP
☐ LLC
☐ LLP
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(Page 1 of 3)
CLEAR
PRINT
LABOR COMMISSIONER, STATE OF CALIFORNIA
DEPARTMENT OF INDUSTRIAL RELATIONS – DIVISION OF LABOR STANDARDS ENFORCEMENT
Initial Report or Claim
FOR OFFICE USE ONLY
Taken by:
Taken by: Office:
Case #:
PLEASE PRINT OR TYPE ALL INFORMATION
Taken by:
Date filed:
SIC #:
Refer to the accompanying Guide to assist you in filling out this form.
RCI Complaint:
Action:
YES
NO
PRELIM IN ARY Q U ESTIO N S
1.
Is your claim about a public works project?
[If your answer is “YES,” STOP here, DO NOT FILL OUT THIS FORM, and fill out the “PW-1” claim
form instead. If your answer is “NO,” proceed with this form.]
2.
Have you filed a retaliation complaint against your employer with the Labor Commissioner?
YES, on: _________/________/________
NO [ If you have been retaliated against, you may file a retaliation
Month
Day
Year
complaint by filling out another form, “DLSE FORM 205.”]
3.
Is there a union contract covering your employment?
YES
[If “YES,” attach a copy of the Collective Bargaining Agreement.]
NO
4.
Are other employees also filing wage claims against your employer?
YES
NO
I DON’T KNOW
Part 1: LAN G U AG E ASSISTAN CE & REPRESEN TATIO N
5a
5b
. Do you need an interpreter?
. If you checked “YES” to Box 5a, enter the language needed
YES
NO
6a
6b
. If you are being assisted with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME
. ADVOCATE’S PHONE
and ORGANIZATION
(
)
6c
CITY
STATE
ZIP CODE
. Your ADVOCATE’S MAILING ADDRESS
(Number, Street, Floor, Suite)
Part 2: YO U R IN FO RM ATIO N
7
8
9
10
11
. Your FIRST NAME
. Your LAST NAME
. HOME PHONE
. OTHER PHONE
. BIRTH DATE
(
)
(
)
12
CITY
STATE
ZIP CODE
. Your MAILING ADDRESS
(Street Number, Street Name, Apartment Number)
Part 3: CLAIM FILED AG AIN ST (EM PLO YER IN FO RM ATIO N )
13
14
15
. EMPLOYER / BUSINESS NAME(S)
.
. EMPLOYER
PHONE
EMPLOYER’S VEHICLE LICENSE PLATE #
(
)
16
CITY
STATE
ZIP CODE
. ADDRESS of EMPLOYER / BUSINESS
(Street Number, Street Name, Floor, Suite):
17
CITY
STATE
ZIP CODE
. ADDRESS where you worked, if different from Box 16
(Number, Street, Floor, Suite):
18
19
. NAME of PERSON IN CHARGE
. JOB TITLE / POSITION of PERSON IN CHARGE
(First Name, Last Name)
20
21
22
23
.
.
.
.
TYPE OF BUSINESS
TYPE OF WORK PERFORMED
TOTAL NUMBER
EMPLOYER STILL IN BUSINESS?
OF EMPLOYEES
YES
NO
DON’T KNOW
24
. Check which box describes your employer, if you know: ☐CORPORATION
☐INDIVIDUAL
☐ PARTNERSHIP
☐ LLC
☐ LLP
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(Page 1 of 3)
PRINT YOUR NAME: ________________________________________
Part 4: FIN AL W AG ES / BO U N CED CH ECK S
25. DATE OF HIRE
26. Check which box applies to you:
____/____/_____
___ /___/____
___/___/____
Still working for employer
QUIT on
DISCHARGED on
Month
Day
Year
Month
Day
Year
Month
Day
Year
Other (specify):
_____________________________________________________________________________________
27a
If you QUIT, did you give 72
27b. If you QUIT, have you received your final payment of wages including all wages owed
?
.
hours notice before quitting?
_______ /_______/_________
YES, on:
YES
Month
Day
Year
NO
NO
28. If you were DISCHARGED, have you received your final payment of wages including all wages owed?
_______ /_______/_________
YES, on:
Month
Day
Year
NO
29b.
If paid by check, did any of your paychecks “bounce”
29a. How were your wages paid?
(for example, paycheck could not be cashed because
employer has insufficient funds)?
BY CHECK
BY CASH
BY BOTH CASH & CHECK
OTHER: __________________________________________
YES
NO
Part 5: H O U RS YO U TYPICALLY W O RK ED
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.
31. If your work hours and days of work were usually the same each week, give your BEST ESTIMATE below of the hours you
usually worked and any time you took for a duty-free meal period during your TYPICAL workweek. DO NOT fill this out if
your work hours were too irregular to estimate a typical or average workweek (instead fill out the DLSE Form 55).
TIME WORK
TIME WORK
1st MEAL
1st MEAL
2nd MEAL
2nd MEAL
ONLY IF YOU WORKED A
STARTED
ENDED
START TIME
END TIME
START TIME
END TIME
SPLIT SHIFT:
(if applicable)
(if applicable)
(if applicable)
(if applicable)
1st shift ended at
2nd shift started at
DAY 1
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
workweek:
_______
pm
_______
pm
1st shift ended at
2nd shift started at
DAY 2
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
_______
pm
_______
pm
1st shift ended at
2nd shift started at
DAY 3
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
_______
pm
_______
pm
1st shift ended at
2nd shift started at
DAY 4
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
_______
pm
_______
pm
1st shift ended at
2nd shift started at
DAY 5
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
_______
pm
_______
pm
1st shift ended at
2nd shift started at
DAY 6
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
_______
pm
_______
pm
1st shift ended at
2nd shift started at
DAY 7
am
am
am
am
am
am
am
am
of your
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
_______
pm
:
workweek
_______
pm
_______
pm
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(CONTINUED – Page 2 of 3)
Part 6: PAYM EN T O F W AG ES
32. Were you paid or promised a FIXED amount of wages per pay period, no matter how many hours you worked (for
example, $400 per week, regardless of how many hours you worked)?
$
YES
I was paid
per
:
day
week
every 2 weeks
month
semi-monthly
___________________
other (specify):__________________________________________________
$
I was promised
_____________ per
day
week
every 2 weeks
month
semi-monthly
other (specify):__________________________________________________
NO
33b.
If you were an HOURLY employee, were you paid or promised more
than one hourly rate (based on the hours you worked or different job
33a. Were you an HOURLY employee?
tasks)?
$
YES
I was paid
per hour.
:
______________
YES (describe):
$
I was promised
_____________ per hour.
NO
NO
34. Were you paid by PIECE RATE?
YES
NO
35. Were you paid by COMMISSION?
YES
NO
Part 7: W AG ES, CO M PEN SATIO N & PEN ALTIES O W ED
36. CLAIMS
CLAIM PERIOD:
CLAIM PERIOD:
AMOUNT EARNED / CLAIMED
(Check all boxes below that apply)
START DATE
END DATE
(Month/ Day/ Year)
(Month/ Day/ Year)
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
$
OTHER (Specify):
$
ENTER SUBTOTAL (add all Amounts Earned/Claimed):
$
ENTER TOTAL AMOUNT PAID:
$
$
GRAND TOTAL OWED [
]:
Subtotal minus Total Amount Paid
***
Additional DLSE form should be submitted if you are making this claim. See “Instructions for Filing a Wage Claim.”
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]
I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection. 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.
Signed: __________________________________________________
Date: ________________________________________________
Print Name: ______________________________________________
DLSE FORM 1 / WAGE ADJUDICATION (REV. 7/2012)
(CONTINUED – Page 3 of 3)
DO NOT WRITE ON THIS SIDE – For Office Use Only
Claimant:
Against:
Interpreter Needed:
Action Number:
Address of Claimant:
Address of Defendant:
Docket Date
Date Closed
DATE(S) CLAIM RECEIVED
Phone No. of Claimant:
Phone No. of Defendant:
Name & Address of Advocate:
Phone No. of Advocate:
Address change of Claimant as of:
Address change of Defendant as of:
DATE BOFE COMPLAINT
DATE RCI COMPLAINT
FILED
FILED
(if applicable)
(if applicable)
RECORD OF RECEIPTS
RECORD OF PAYMENTS TO CLAIMANT
Date
Check,
Receipt Number
Amount
Division Check
Date Paid
Balance Due
Signature/Remarks
Received
Cash, etc.
Number
CONFERENCE: DATES
PEND: DATES
NOTES:
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