Printed by the authority of the State of Illinois
(revised 12/13/22)
ILLINOIS DEPARTMENT OF LABOR
Fair Labor Standards Division
160 N. LaSalle Street -Suite C-1300
Chicago, Illinois 60601-3150
Telephone: 312-793-2800 http://labor.illinois.gov
INSTRUCTIONS FOR WAGE CLAIM & MINIMUM WAGE COMPLAINT FORM
Please be aware that the complaint must be filed within one (1) year after wages, final
compensation, or wage supplements were due.
• Print your answers clearly and complete the form where applicable.
• Sign and date the application.
• Make at least three (3) copies of the claim application and ALL THE ATTACHMENTS.
o Provide one (1) signed copy of the claim application WITH ALL THE ATTACHMENTS to the Illinois
Department of Labor.
o Please keep one signed copy for your records and keep at least one signed copy for serving
documents to the employer. Be advised that any document that a party intends to introduce as evidence
during an investigation by the Department should be served by the party on the other party. You may use the
“Certificate of Service” found at https://labor.illinois.gov/content/dam/soi/en/web/idol/certificate-of-service.pdf at
a Department of Labor hearing as (rebuttable) evidence that you had delivered documents to the other party.
IDOL will not provide copies of any of your documents (other than the Wage Claim application) to any party.
• Provide the correct name and address of your employer. If the employer is a corporation or Limited Liability
Corporation (LLC), you can search the Secretary of State website to verify the employer's address at
http://www.ilsos.gov/corporatellc/. This is a public site for locating companies in Illinois. If you do not have access to
Internet, you can visit your local public library.
• You must provide an address where both the Department and opposing party (Employer) may serve you documents.
It does not need to be your home address but should be an address to where legal documents may be sent and an
address that you will check regularly.
• If you wish to expedite the process, the Department suggests that you provide an email address where documents
can be served to you by the Department as well as the opposing party.
• If applicable, provide the name, address, and phone number of the attorney or community representative that helped
you complete the form.
• You must update the Department in writing immediately if you have a change of address, phone number or email. If
the Department recovers money on your behalf, we need your current address in order to send you your check.
• Do not submit any personal information, such as Social Security numbers, driver license numbers and bank
or medical information. Redact or block out this information from the documents you submit.
To be able to proceed with your WAGE CLAIM,
please follow these steps to complete your application:
WAGE CLAIM:
For unpaid wages, vacation pay, bonus, commissions or if you believe your employer has made illegal deductions from
your pay, proceed to complete both the General Information AND Section 1 of this form only.
You may submit the form by email to [email protected]
MINIMUM WAGE/OVER TIME:
The minimum wage for hourly and non-exempt workers in the state of Illinois is $14.00. Overtime is all time worked over 40
hours in a scheduled workweek for hourly and nonexempt workers. For minimum wage and/or overtime claims, proceed to
complete both General Information AND Section 2 of this form only.
You may submit the form by email to [email protected]
If you are filing a wage claim AND a minimum wage/overtime claim, please complete both Sections 1 and 2.
Print Form
Printed by the authority of the State of Illinois
(revised 12/13/22)
• If you believe you are owed wages:
o Attach one (1) copy of paychecks, paycheck stubs, W2's, 1099's or any other documentation, such as emails or
letters, that is relevant to your claim. DO NOT SUBMIT ORIGINALS.
• If you believe you are owed vacation pay:
o Attach one (1) copy of the vacation policy or an explanation of the vacation policy, plus W2's, 1099's, paycheck
stubs or any other documentation, such as emails or letters, that is relevant to your claim.
DO NOT SUBMIT ORIGINALS.
• If you believe you are owed a bonus:
o Attach one (1) copy of the bonus agreement or an explanation of the policy plus W2's, 1099's , paycheck stubs or
any other documentation, such as emails or letters, that is relevant to your claim. DO NOT SUBMIT ORIGINALS.
• If you believe you are owed a commission payment:
o Attach one (1) copy of the commission agreement or an explanation of the policy plus W2's, 1099's, paycheck stubs
or any other documentation, such as emails or letters, that is relevant to your claim. DO NOT SUBMIT ORIGINALS.
• If you believe your employer has illegally deducted money from your pay:
o Attach one (1) copy of the documentation that shows the deduction (Examples: paycheck stubs or a letter
authorizing the deduction) or any other documentation, such as emails or letter, that is relevant to your claim.
DO NOT SUBMIT ORIGINALS.
• Submit your completed application and documentation to the Illinois Department of Labor in person, by email
at [email protected] or by U.S. mail at 160 N. LaSalle Street, Suite C-1300, Chicago, IL 60601-3150.
To be able to proceed with your MINIMUM WAGE and/or OVERTIME claim,
please follow these steps to complete your application:
• Print or type your answers.
• Sign and date the application.
• Make at least 2 copies of the claim application and ALL THE ATTACHMENTS.
o Provide one (1) signed copy of the claim application WITH ALL THE ATTACHMENTS to the Department of
Labor.
o Please keep one (1) copy for your records.
• Verify that you are providing the correct name and address of your employer. You can search the Secretary of State
website to verify the employer's address at http://www.ilsos.gov/corporatellc/. This is a public site for locating
companies in Illinois. If you do not have access to Internet, you can visit your local public library.
• If applicable, provide the name, address and phone number of the attorney or community representative that helped
you complete the form.
• You must update the Illinois Department of Labor in writing immediately if you have a change of address, phone
number or email. If the Department recovers money on your behalf we need your current address in order to send
you your check.
• Don't submit any personal information, as Social Security or driver license numbers, medical or bank
information. Please block out or redact this information from the documents you submit.
• If your claim is exclusively for minimum wage and overtime violations, you may choose to remain anonymous by
selecting the option on Section 2 of the application. However, your name will be revealed if you also filed a Wage
Claim against the employer, or the employer paid you in cash and/or did not keep time records, or if you are no
longer working for the employer named in this complaint.
• Submit your completed application and documentation to the Illinois Department of Labor in person, by email
at [email protected] or by mail at 160 N. LaSalle Street, Suite C-1300, Chicago IL 60601-3150
Additionally:
Your name and address will be revealed to your employer if you are claiming unpaid wages, vacation,
bonuses, commissions, or illegal deductions.
• Please be aware that if you complete both Section 1 and Section 2 of the application, this will result in two
separate complaints filed and reviewed by different sections of the Fair Labor Standards Division. In this case you
will need to provide to the Department two complete copies of all the documentation.
• Claims filed under Section 1 will be reviewed by the Wage Claim Section and claims filed under Section 2 will be
reviewed by the Compliance Section. Two separate investigators will be assigned to your claims: a Wage Claim
Specialist for Section 1 (Wage Claims), and a Compliance Officer for Section 2 (Minimum Wage and Overtime
Claims).
Printed by the authority of the State of Illinois
Page 1 of 3
(revised 12/13/22)
Illinois Department of Labor
160 N. LaSalle, Suite C-1300 Chicago IL 60601-3150
Telephone #: (312) 793-2800
http://labor.illinois.gov
Claim #
Office use only
M
UNPAID WAGES CLAIM AND MINIMUM WAGE/OVERTIME CLAIM
CLAIMANT INFORMATION
GENERAL INFORMATION
EMPLOYER INFORMATION
(Last Name) (First Name) (Middle Name) Business Name
(Street Address)
(This will be released to the Employer)
Business Owner(s) name(s)
(City)
(Primary phone #)
(State)
(Zip code) (County)
(Secondary phone #)
(Street Address)
(City)
(State)
(Zip code) (County)
Yes No
Yes
Email Address:
(very important)
I authorize service of documents by E-mail:
Yes
Yes No
6) Did you sign an employment contract or agreement?
Yes
Please attach
Hourly
Biweekly
Other
7)
Were you in a union?
No
8) Has the company filed for Bankruptcy OR made an Assignment for Benefit for Creditors?
Yes
Please attach
No
9) Is
the company still open?
Yes No
10) Is this a temporary staffing agency?
Yes No
Phone:
Email:
11) If applicable, name of your attorney or representative:
12) If applicable, name of person who
prepared this form:
Phone:
12(a) Can we contact this person in relation to your claim? Yes
Is this claim for:
Overtime
Email:
13) Do you need an interpreter? Yes
If you checked "Yes", enter the language needed:
SECTION 1 : WAGE CLAIM APPLICATION
I. UNPAID WAGES
Other:
To:
1099 Form
Emails Letters Other (Specify)
For unpaid wages, vacation pay, bonus, commissions or if you believe your employer has made illegal deductions from your pay, proceed
to complete both the General Information AND Section 1 of this form only. You can submit the form by email to [email protected]
For unpaid minimum wages ($14.00 in the State of Illinois for hourly and non exempt workers) and unpaid overtime (all time worked over 40
hours in a schedule work week), proceed to complete both General Information AND Section 2 of this form only. You can submit the form by
email to [email protected]
Who is responsible for issuing pay? (Personnel/HR Manager)
No
3) Still working there?
2) Last day worked:
1) Date of hire:
No
5) Did you also perform the work in other states?
No Rate of Pay:
Yes
Please attach
No
Regular Time
FOR TRANSLATORS/INTERPRETERS
No
Amount claimed:
A. How many hours did you work and not get paid?
B. How much were you paid? Hourly:
Bi-weekly:
C. Dates for which you were not paid:
D.
What type of work did you perform?
From:
I am attaching the following supporting documentation: (DO NOT SEND ORIGINALS)
Employment Contract/Agreement
Paycheck
Pay stub
4) Did you perform the work in Illinois?
([email protected])
Business Phone:
President's Email Address:
Minimum Wage Violations
Name and Local:
W2 Form
Print Form
Printed by the authority of the State of Illinois
Page 2 of 3
(revised 12/13/22)
II. VACATION
PAY
III. BONUS
Yes
No
Yes No
C. What is the vacation policy?
Attach a copy of the vacation policy.
What was the policy or agreement? Attach a copy of the policy.
I am attaching the following supporting documentation:
(DO NOT SEND ORIGINALS)
I am attaching the following supporting documentation:
(DO NOT SEND ORIGINALS)
Vacation Policy
1099 Form
W2 Form
Bonus Agreement/Policy
W2 Form
1099 Form
Emails
IV. COMMISSION
To:
Emails Letters
V. ILLEGAL DEDUCTIONS
A. How much are you owed?
B. For what period of time? From:
C. Are you still employed by this employer?
Yes No
Yes No
D. Explain why you are owed a commission. Attach the commission policy.
I am attaching the following supporting documentation:
(DO NOT SEND ORIGINALS)
I am attaching the following supporting documentation:
(DO NOT SEND ORIGINALS)
Commission Agreement/Policy
1099 Form
Paycheck Pay stub
1099 Form
Emails
Letters
Emails
Letters
Employment Contract/Agreement
VI. OTHER
I am attaching the following supporting documentation: (DO NOT SEND ORIGINALS)
Paycheck Pay stub W2 Form 1099 For
m
E
mp
l
oyment Contract/Agreement
Emails Letters Other (specify)
P
age 2 of 3
A. How much are you owed?
B. Are you still employed by this employer?
A. How much are you owed?
B. Are you still employed by this employer?
C. Explain why you believe you are owed a bonus.
Employment Contract/Agreement
Other (specify)
A. How much was deducted?
B. When did the deduction occur?
C. Did you agree to this deduction in writing?
D. Explain how much was deducted and why. Attach copies of evidence.
Other (specify)
Explain what you are owed and why? Attach additional sheets if necessary.
TOTAL AMOUNT CLAIMED UNDER SECTION 1:
(Do not include Total Amount Claimed from Section 2)
Paycheck
Pay stub
Employment Contract/Agreement
Letters
Other (specify)
Paycheck
Pay stub
W2 Form
P
aycheck
Pay stub
Employment
Contract/Agreement
Other (specify)
W2 Form
Printed by the authority of the State of Illinois
SECTION 2: MINIMUM WAGE AND/OR OVERTIME CLAIM APPLICATION
From: To:
Wages per hour:
Tips per hour:
Yes No
Yes No
Did your position require a college degree?
Yes No
Yes No
Additional Comments:
TOTAL AMOUNT CLAIMED UNDER SECTION 2 :
I HEREBY CERTIFY that the application, including attachments, is true and accurate to the best of my knowledge and belief.
I UNDERSTAND that acceptance of this claim by the Illinois Department of Labor does not guarantee collection.
I AUTHORIZE the Department of Labor to receive any monies and to mail such monies to me at my address on file with the
Illinois Department of Labor.
Date: Claimant's Signature:
Page 3 of 3
(revised 12/13/22)
([email protected])
Salary Hourly
Attach copies of supporting documentation such as pay stubs, W2's, 1099's. DO NOT SEND ORIGINALS.
Date of birth:
Dates for which you were not paid:
From:
To:
How were you paid?
Meals
Lodging
Actual Hours
Worked Per Week:
Check if you received:
Tips
Other
Total number of employees:
Dates of Employment:
ONLY For Minimum Wage and Overtime claims: (Does not apply to claims for unpaid wages, deductions, vacation, bonus, commissions.)
I do not want my name revealed to the employer.
(This option does not apply if you are no longer working for the employer named in this complaint.)
Overtime Claims:
Your Title:
Were you a professional employee?
Were you a manager?
List your primary duties:
Did you supervise anyone?
Other