Delaware Wage Claim Form Preparation Worksheet
Delaware Wage Claim Form Preparation Worksheet
Before use: Complete the Delaware Department of Labor Wage Claim Form to make the claim. This worksheet helps gather information for its sections A through H. The agency form includes its own assignment, certification, signature, and delivery instructions. Check the current form for its filing limits and time guidance before submitting it.
Prepared by: [NAME]
Date: [__/__/____]
Agency form version checked: [DATE OR REVISION]
1. Claimant and employer
Claimant's full name: [NAME]
Address: [STREET, CITY, STATE, ZIP]
Phone and email: [PHONE; EMAIL]
Interpreter needed and language, if any: [DETAILS]
Employer's legal or business name: [NAME]
Employer's address: [STREET, CITY, STATE, ZIP]
Contact person, phone, and email: [DETAILS]
Business type and corporate address, if known: [DETAILS]
Subcontractor or hiring company, if relevant: [DETAILS]
2. Employment and pay terms
Job title and duties: [DETAILS]
Where hired and where work was done: [DETAILS]
First and last dates worked: [__/__/____] to [__/__/____]
Still employed? ☐ Yes ☐ No; if no, separation date and reason: [DETAILS]
Pay arrangement: ☐ Hourly at $[AMOUNT] ☐ Salary of $[AMOUNT] ☐ Other: [DETAILS]
Pay frequency and method: [DETAILS]
Written or oral wage agreement; person who explained it: [DETAILS]
Union or collective bargaining agreement and grievance status, if any: [DETAILS]
3. Amounts claimed
| Category | Period or basis | Gross amount claimed | Payments or credits | Balance |
|---|---|---|---|---|
| Unpaid regular wages | [DATES / HOURS / RATE] | $[____] | $[____] | $[____] |
| Overtime or minimum-wage shortfall | [DATES / HOURS / RATE] | $[____] | $[____] | $[____] |
| Commissions or tips | [BASIS] | $[____] | $[____] | $[____] |
| Vacation, holiday, or other wage supplement | [POLICY / BASIS] | $[____] | $[____] | $[____] |
| Disputed deduction | [DATE / REASON] | $[____] | $[____] | $[____] |
| Total | $[____] | $[____] | $[____] |
Claim period: [__/__/____] to [__/__/____]
Last date paid: [__/__/____]
Last payment received and how paid: [AMOUNT, DATE, METHOD]
Amount already requested from employer; date and response: [DETAILS]
Calculation details, including any draw against commissions: [DETAILS]
4. Records and witnesses
☐ Pay stubs or payroll statements: [DATES]
☐ Time cards, schedules, logs, or sales records: [DETAILS]
☐ Wage agreement, offer letter, or contract: [DETAILS]
☐ Policies for vacation, holiday, bonus, or other supplement: [DETAILS]
☐ Documents showing deductions or tip pooling: [DETAILS]
☐ Messages requesting payment or explaining nonpayment: [DETAILS]
☐ Other records: [DETAILS]
Witness names, contact information, and what each observed: [DETAILS]
5. Narrative for the agency form
When and how pay was promised: [DETAILS]
Work performed and amount earned: [DETAILS]
What was paid, what remains unpaid, and how the balance was calculated: [DETAILS]
What the employer said about nonpayment or deductions: [DETAILS]
Other court or agency claim concerning these wages, including docket number: [DETAILS]
6. Transfer to the official form
☐ Enter all applicable answers in sections A through H of the current agency form.
☐ Mark any inapplicable agency-form section as directed by that form.
☐ Attach copies of supporting records and keep a complete copy.
☐ Read the agency form's assignment and consent language before signing it.
☐ Submit the signed agency form by a channel listed on the current form and retain proof of submission.
Official claim form and instructions: Delaware Department of Labor Wage Claim Form.
Current agency page: Division of Industrial Affairs, Wage & Hour.
Statute: 19 Del. C. § 1113.
About this template
- Last updated
- November 2, 2026
- Citations checked
- November 2, 2026
- Jurisdiction
- Delaware
- Category
- Employment & HR
Legal authority
- 19 Del. C. § 1113(b)
- Delaware Department of Labor, Division of Industrial Affairs, Wage Claim Form (Rev. 7/22/24)
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 2, 2026.
19 Del. C. § 1113(b) (checked November 2, 2026): "Whenever the Department determines that wages, as required under this chapter, have not been paid, the Department may bring any legal action necessary to collect such claim."
Delaware Department of Labor, Division of Industrial Affairs, Wage Claim Form (Rev. 7/22/24) (checked November 2, 2026): "The completed Intake Questionnaire and any supporting documentation may be submitted by mail, fax, email or in- person."
Delaware Division of Industrial Affairs, Wage & Hour (checked November 2, 2026): "Use this form if you believe you have not been paid correctly, including unpaid wages, overtime, or minimum wage violations."
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