GIG WORKER MINIMUM WAGE CLAIM

SECTION 1: CLAIMANT INFORMATION

Full Legal Name: _______________________________________________

Address: _______________________________________________

City, State, ZIP: _______________________________________________

Email: _______________________________________________

Phone: _______________________________________________

Social Security Number (last 4 digits): XXX-XX-___________

Platform Account/Worker ID: _______________________________________________

Date of Claim: _______________________________________________

SECTION 2: EMPLOYER/PLATFORM INFORMATION

Platform Name: _______________________________________________

Legal Entity Name: _______________________________________________

FEIN (if known): _______________________________________________

Address: _______________________________________________

City, State, ZIP: _______________________________________________

SECTION 3: EMPLOYMENT INFORMATION

Work Performed:
☐ Rideshare driving
☐ Food delivery
☐ Grocery delivery
☐ Package delivery
☐ Other: _______________________________________________

Dates of Employment:
- Start date: _______________________________________________
- End date (if applicable): _______________________________________________
- Currently working for platform: ☐ Yes ☐ No

Claim Period: From _______________ to _______________

Primary Work Location (City, State): _______________________________________________

SECTION 4: APPLICABLE MINIMUM WAGE RATES

FEDERAL MINIMUM WAGE

• Current federal minimum wage: $7.25/hour
• Overtime rate (1.5x): $10.88/hour

STATE MINIMUM WAGE

Select your state:

☐ California
- 2024: $16.00/hour
- 2025: $16.50/hour (projected)
- 2026: Check current rate: $______/hour
- Fast food workers (AB 1228): $20.00/hour (if applicable)
- Proposition 22 guarantee: 120% of minimum wage for engaged time

☐ Massachusetts
- 2024: $15.00/hour
- 2025: $15.00/hour
- 2026: Check current rate: $______/hour

☐ New Jersey
- 2024: $15.13/hour
- 2025: Adjusted annually
- 2026: Check current rate: $______/hour

☐ New York
- NYC (large employers): $16.00/hour (2024)
- NYC (small employers): $16.00/hour (2024)
- Long Island/Westchester: $16.00/hour (2024)
- Rest of state: $15.00/hour (2024)
- 2026: Check current rate: $______/hour

☐ Other State: _______________________________________________
- Current rate: $______/hour

LOCAL MINIMUM WAGE

☐ Higher local minimum wage applies

City/County: _______________________________________________
Local minimum wage: $______/hour
Effective date: _______________________________________________

APPLICABLE RATE FOR THIS CLAIM

Highest applicable minimum wage rate: $______/hour

SECTION 5: HOURS AND EARNINGS CALCULATION

A. TIME TRACKING METHOD

How were hours tracked?
☐ Platform app (automatic)
☐ Personal time log
☐ GPS/mileage-based estimate
☐ Other: _______________________________________________

B. DEFINITION OF COMPENSABLE TIME

Time that should be compensated:

☐ All Time Online/Available (Traditional Employee Model)
- Includes time logged into app waiting for orders
- Includes time between deliveries/rides
- Includes time traveling to pickup locations

☐ Engaged Time Only (Prop 22/Platform Model)
- Time from accepting order to completing delivery
- Time from accepting ride to dropping off passenger
- Does NOT include waiting time between assignments

Model Used for This Claim: _______________________________________________

C. WEEKLY HOURS AND EARNINGS RECORD

Instructions: Complete for each week in the claim period. Use additional sheets as needed.

Week 1:
- Week ending: _______________________________________________
- Total hours worked: _______________________________________________
- Hours over 40: _______________________________________________
- Gross earnings from platform: $_______________________________________________
- Expenses incurred: $_______________________________________________

Week 2:
- Week ending: _______________________________________________
- Total hours worked: _______________________________________________
- Hours over 40: _______________________________________________
- Gross earnings from platform: $_______________________________________________
- Expenses incurred: $_______________________________________________

Week 3:
- Week ending: _______________________________________________
- Total hours worked: _______________________________________________
- Hours over 40: _______________________________________________
- Gross earnings from platform: $_______________________________________________
- Expenses incurred: $_______________________________________________

Week 4:
- Week ending: _______________________________________________
- Total hours worked: _______________________________________________
- Hours over 40: _______________________________________________
- Gross earnings from platform: $_______________________________________________
- Expenses incurred: $_______________________________________________

(Continue on attached sheet for additional weeks)

D. SUMMARY CALCULATION

SECTION 6: MINIMUM WAGE VIOLATION CALCULATION

METHOD 1: TRADITIONAL EMPLOYEE CALCULATION

All Hours Worked Approach:

METHOD 2: NET WAGE CALCULATION (AFTER EXPENSES)

Effective Wage Approach:

METHOD 3: CALIFORNIA PROPOSITION 22 CALCULATION

(For California app-based drivers only)

SELECTED CALCULATION METHOD

☐ Method 1: Traditional Employee
☐ Method 2: Net Wage (After Expenses)
☐ Method 3: California Proposition 22

Total Minimum Wage Shortfall: $_______________________________________________

SECTION 7: ADDITIONAL DAMAGES AND PENALTIES

FEDERAL LAW (FLSA)

☐ Liquidated Damages
Under 29 U.S.C. § 216(b), workers are entitled to liquidated damages equal to unpaid wages unless employer proves good faith.

STATE-SPECIFIC PENALTIES

CALIFORNIA

☐ This claim includes California penalties

MASSACHUSETTS

☐ This claim includes Massachusetts penalties

NEW JERSEY

☐ This claim includes New Jersey penalties

NEW YORK

☐ This claim includes New York penalties

SECTION 8: TOTAL CLAIM SUMMARY

SECTION 9: LEGAL BASIS

EMPLOYEE STATUS CLAIM

I assert that I am an employee, not an independent contractor, because:

☐ Under DOL 2024 Economic Reality Test:
- I am economically dependent on the platform
- I have no opportunity for profit based on managerial skill
- My work is integral to the platform's business
- The platform controls significant aspects of my work
- The relationship is ongoing, not project-based
- I have not made significant capital investments

☐ Under State ABC Test (CA, MA, NJ):
The platform cannot prove all three prongs:
- (A) Free from control: _______________________________________________
- (B) Outside usual course of business: _______________________________________________
- (C) Independently established trade: _______________________________________________

ALTERNATIVELY: PLATFORM GUARANTEE CLAIM

☐ Under California Proposition 22:
Even if classified as independent contractor, I am entitled to:
- 120% of minimum wage for engaged time
- $0.30/mile for vehicle expenses
- Healthcare stipend (if eligible)

The platform has failed to meet these guarantees.

SECTION 10: SUPPORTING DOCUMENTATION

Attached Documents:

☐ Platform earnings statements/pay records
☐ Personal time log
☐ GPS/mileage records
☐ Expense receipts
☐ Platform app screenshots
☐ Tax documents (1099)
☐ Bank statements showing payments
☐ Calculation spreadsheet
☐ Communications with platform
☐ Other: _______________________________________________

SECTION 11: FILING OPTIONS

ADMINISTRATIVE CLAIMS

Federal:
☐ U.S. Department of Labor, Wage and Hour Division
- File at: dol.gov/agencies/whd/contact/complaints
- Phone: 1-866-487-9243

State:
☐ California Labor Commissioner (DLSE)
☐ Massachusetts Attorney General
☐ New Jersey Department of Labor
☐ New York Department of Labor
☐ Other state agency: _______________________________________________

LEGAL ACTION

☐ Individual lawsuit
☐ Collective action (FLSA)
☐ Class action (state law)
☐ Arbitration (if required)
☐ PAGA representative action (California)

SECTION 12: DECLARATION

I declare under penalty of perjury under the laws of the United States and the State of _______________ that the foregoing is true and correct.

I have calculated the hours worked and wages owed to the best of my ability based on available records. I understand that I may be required to provide additional documentation to support this claim.

Signature: _______________________________________________

Printed Name: _______________________________________________

Date: _______________________________________________

Location: _______________________________________________

SECTION 13: DEMAND LETTER

[DATE]

[PLATFORM NAME]
[LEGAL/HR DEPARTMENT]
[ADDRESS]

RE: Minimum Wage Claim
Worker ID: _______________
Claim Period: _______________ to _______________

Dear Sir or Madam:

I am a worker on your platform. This letter constitutes formal demand for payment of unpaid minimum wages and related damages.

Summary of Claim:

Legal Basis: [Federal/State] minimum wage laws require that I receive at least $_____ per hour for all hours worked. During the claim period, my effective hourly rate was only $_____, resulting in the shortfall claimed above.

Demand: Payment of $_________ within fourteen (14) days.

Consequences of Non-Payment: I will file complaints with the U.S. Department of Labor and [state agency], initiate legal action, and seek all available remedies including attorney's fees.

Sincerely,

_______________________________________________
[Signature]

WEEKLY TIME AND EARNINGS LOG

NOTES

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