New Hampshire Wage Claim Form Preparation Worksheet
NEW HAMPSHIRE WAGE CLAIM FORM PREPARATION WORKSHEET
Before you use this: The Department of Labor distinguishes a wage claim from a report of a wage complaint. A wage claim asks the Department to adjudicate unpaid wages against the employer. File through the Department's online wage claim route or official PDF form, not this worksheet. Current RSA 275:51(V), amended effective July 7, 2026, permits filing no later than 36 months from when the wages were due. Its current text provides a hearing if requested; the Department's web description of a claim as a hearing request should be read with that newer text.
1. Claimant and employer
Your name: [________________________________]
Mailing address: [________________________________]
Phone and optional email: [________________________________]
Employer's establishment name: [________________________________]
Employer's mailing address and phone: [________________________________]
Employer representative and title, if known: [________________________________]
Type of business and employer identification number, if known: [________________________________]
Did you complete a W-4 for this employer? ☐ Yes ☐ No ☐ Unsure
Was your employer a subcontractor? ☐ Yes ☐ No ☐ Unsure
If yes, prime contractor name, address, and phone: [________________________________]
Employee leasing company, if applicable, with address and phone: [________________________________]
2. Work and wages claimed
Type of work and location: [________________________________]
Describe what wages you believe are owed, the work and pay arrangement, and the employer's response if you asked for payment: [________________________________]
| Wage item | Work period | Date payment was due | Earned | Paid | Owed |
|---|---|---|---|---|---|
| [ITEM] | [DATES] | [DATE] | $[____] | $[____] | $[____] |
| [ITEM] | [DATES] | [DATE] | $[____] | $[____] | $[____] |
| Total amount claimed | $[____] | $[____] | $[____] |
For each wage item, calculate 36 months from its due date and record the filing date you need to meet: [________________________________]
Supporting records to gather: ☐ time records ☐ pay stubs ☐ wage agreement ☐ commission or benefit policy ☐ messages ☐ bank records ☐ other [________________________________]
3. Complete the official claim
☐ Open the Department's current filing instructions. Choose the online web form or the official Wage Claim PDF. The PDF's Social Security number and email fields are marked optional; enter sensitive information only on the agency's official form if you choose to provide it.
☐ Transfer the employer, work, claim narrative, and total amount to the official form. Add pages if needed and review its certification before signing.
☐ If using the PDF, follow the Department's current mail or email directions for its Hearings Bureau. Its page lists [email protected] and 95 Pleasant Street, Concord, NH 03301.
☐ If you want a hearing, ask the Hearings Bureau how to request one under current RSA 275:51(V).
Submission date, method, and confirmation: [________________________________]
Keep a copy of the signed claim, supporting records, and proof of delivery.
Official sources
About this template
- Last updated
- October 27, 2026
- Citations checked
- October 27, 2026
- Jurisdiction
- New Hampshire
- Category
- Employment & HR
Legal authority
- N.H. Rev. Stat. Ann. § 275:51(V)
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.
N.H. Rev. Stat. Ann. § 275:51(V) (checked October 27, 2026): "A wage claim may be filed by an employee or by the department on its own motion no later than 36 months from the date the wages were due."
New Hampshire Department of Labor Wage Claim Form (checked October 27, 2026): "I hereby certify that this is a true statement of the wages owed me by the above employer."
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