Rhode Island Nonpayment of Wages Complaint Preparation Worksheet
RHODE ISLAND NONPAYMENT OF WAGES COMPLAINT PREPARATION WORKSHEET
Before you use this: The Rhode Island Department of Labor and Training provides a two-page Non-Payment of Wages Complaint Form. Use that form for an agency complaint. This worksheet helps organize the facts to transfer; it is not the complaint and does not submit it. An employer demand letter serves a different purpose.
1. Worker and employer
Your name: [________________________________]
Current mailing address, phone, and email: [________________________________]
Job title or work performed: [________________________________]
Employer's legal or business name, other names used, worksite address, and phone: [________________________________]
Person in charge and title: [________________________________]
Different location where you worked, if any: [________________________________]
Employment start date: [__/__/____] Separation date, if applicable: [__/__/____]
Reason employment ended, if applicable: [________________________________]
Attorney representing you on this matter, if any: [________________________________]
2. Pay arrangement and amount claimed
Usual hours per week: [____] Pay rate and pay basis: [________________________________]
Problem to describe on the agency form: ☐ missing final pay ☐ commission ☐ overtime ☐ minimum wage ☐ paid sick or safe leave ☐ deduction ☐ other [________________________________]
| Work period and wage item | Hours or other calculation basis | Amount expected | Amount paid | Amount claimed |
|---|---|---|---|---|
| [DATES / ITEM] | [BASIS] | $[____] | $[____] | $[____] |
| [DATES / ITEM] | [BASIS] | $[____] | $[____] | $[____] |
| Total | $[____] | $[____] | $[____] |
Explain the calculation and any employer response: [________________________________]
Did you ask the employer for payment? ☐ Yes ☐ No
If yes, identify whom you asked, when, and the response: [________________________________]
If no, explain why: [________________________________]
Written employment or independent-contractor agreement? ☐ Yes ☐ No
Records to gather: ☐ pay statements ☐ time records ☐ schedules ☐ messages ☐ payment records ☐ agreement ☐ written vacation policy, if claiming vacation pay ☐ other [________________________________]
3. Complete the agency form
☐ Open the current Rhode Island wage complaint page and its official Non-Payment of Wages Complaint Form. Complete both pages, including the employer information, to the best of your knowledge.
☐ Transfer the dates, wage calculation, total claimed, explanation, and relevant supporting records to the official form. Provide any sensitive identifier only on the agency form, through its stated submission channel.
☐ Read the form's certification and assignment language before signing. Complete its signature and date fields, including the parent-signature field if the claimant is a minor.
☐ Follow the official form's current mail or email directions. The form says not to fax it. Keep a copy and proof of submission, and tell the agency if your contact information changes or you receive payment.
Date and method submitted: [________________________________]
Agency confirmation or case number, if provided: [________________________________]
Official source
About this template
- Last updated
- November 1, 2026
- Last reviewed
- November 1, 2026
- Jurisdiction
- Rhode Island
- 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 November 1, 2026.
Rhode Island Department of Labor and Training, Non-Payment of Wages Complaint Form (rev. 02/25) (checked November 1, 2026): "Complete both sides of this form, sign and return to the address above or email to [email protected]; do not fax."
Rhode Island Department of Labor and Training, Non-Payment of Wages Complaint Form, employer information (checked November 1, 2026): "EMPLOYMENT INFORMATION: (complaint will not be accepted unless this section is completed.)"
Draft your Rhode Island Nonpayment of Wages Complaint Preparation Worksheet in the editor
Answer a few questions, let the AI editor draft each section from your answers, review it, and download Word and PDF. $99 one time, or $249 per month for every document and every Ezel app.