South Dakota Claim of Unpaid Wages Preparation Worksheet
SOUTH DAKOTA CLAIM OF UNPAID WAGES PREPARATION WORKSHEET
Before you use this: The South Dakota Department of Labor and Regulation directs a worker with a wage dispute, including unpaid wages or pay below the minimum wage, to complete its official Claim of Unpaid Wages form. That page links to the current electronic form. This worksheet helps assemble your facts; it is not the agency form and does not file a claim. A final-pay demand sent to an employer is a separate document.
1. Worker and employer
Your name and contact information: [________________________________]
Employer's business name, worksite, and contact information: [________________________________]
Supervisor or payroll contact, if known: [________________________________]
Job title and duties: [________________________________]
First and last dates worked: [________________________________]
Are you still employed there? ☐ Yes ☐ No; last day: [__/__/____]
Where was the work performed? [________________________________]
2. Wages in dispute
Describe the pay problem: ☐ Unpaid wages ☐ Pay below minimum wage ☐ Final pay ☐ Other wage dispute [________________________________]
Pay rate, method, and regular payday under your agreement or employer's policy: [________________________________]
| Work period or wage item | Hours, units, or other basis | Amount earned | Amount paid | Difference |
|---|---|---|---|---|
| [ITEM / DATES] | [BASIS] | $[____] | $[____] | $[____] |
| [ITEM / DATES] | [BASIS] | $[____] | $[____] | $[____] |
| Total | $[____] | $[____] | $[____] |
Dates payment was expected and dates any partial payment arrived: [________________________________]
Explain the calculation and identify the supporting pay agreement, schedule, time record, or policy: [________________________________]
3. Timeline and records
What did you ask the employer to pay? Record each request date, delivery method, amount, and response: [________________________________]
Documents to have ready: ☐ pay statements ☐ time records ☐ schedule ☐ written agreement ☐ messages ☐ payment records ☐ other [________________________________]
4. Transfer to the official form
☐ Open the Department's Wage and Hour Issues page and select its Claim of Unpaid Wages link. Complete the current electronic form's questions and acknowledgments; this worksheet does not substitute for them.
☐ Review the wage calculation and attach or provide supporting records as the official form directs. Keep copies of what you submit and any confirmation.
☐ For a question about the correct route, contact the Division of Labor and Management using the contact information on the Department page.
Submission date and confirmation reference: [________________________________]
Official sources
About this template
- Last updated
- October 27, 2026
- Last reviewed
- October 27, 2026
- Jurisdiction
- South Dakota
- Category
- Employment & HR
Employment documents govern the relationship between a company and its workers, from offer letters and employment agreements through handbooks, performance reviews, and separations. Done right, they set clear expectations, protect against wrongful termination and discrimination claims, and give both sides a record to rely on. Done poorly, they invite lawsuits, agency complaints, and costly disputes.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 27, 2026.
South Dakota Department of Labor and Regulation, Wage and Hour Issues (checked October 27, 2026): "You can file a wage dispute, including claim of unpaid wages (wages owed) or not being paid at least minimum wage, by completing the Claim of Unpaid Wages form."
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