D.C. Wage Payment Claim Preparation Worksheet - District of Columbia

D.C. Wage Payment Claim Preparation Worksheet

Before use: The Office of Wage-Hour currently links a five-page Wage Payment Claim Form, Rev. 02/25. Put the answers gathered here on that form, review its sworn verification, sign it, and submit it with supporting records using the agency's current instructions. This worksheet is only a drafting aid. Use the agency's separate form for a minimum-wage or overtime claim when that is the claim being made.

Prepared by: [NAME]
Date: [__/__/____]
Official form revision checked: [DATE]

1. Claim and contact information

Work location in the District: [STREET, CITY, ZIP]
Claimant's full name: [NAME]
Mailing address: [ADDRESS]
Daytime phone and email: [PHONE; EMAIL]
Interpretation or translation needed; primary language: [DETAILS]
Hired as a subcontractor or self-employed? ☐ Yes ☐ No; details: [DETAILS]

Employer's business name and owner's name: [NAMES]
Business address, phone, and email: [DETAILS]
Type of business and approximate employee count: [DETAILS]
Business closed or in bankruptcy? ☐ Yes ☐ No ☐ Unknown

2. Employment and pay history

Work performed: [DUTIES]
Date hired: [__/__/____]
Status: ☐ Still employed ☐ Resigned ☐ Discharged
Last day worked and separation date, if applicable: [DATES]
Reason given for separation: [DETAILS]
Supervisor's name: [NAME]
Pay rate and unit: $[AMOUNT] per [HOUR / DAY / WEEK / OTHER]
Usual payday, pay period end, and frequency: [DETAILS]
Payment method: ☐ Check ☐ Cash ☐ Both ☐ Other: [DETAILS]
Usual schedule, including breaks: [DAYS, HOURS, BREAKS]
Employer time records and records available to you: [DETAILS]
Possible independent-contractor misclassification: [FACTS, IF ANY]

3. Wage calculation for transfer to the agency form

Unpaid period: [__/__/____] through [__/__/____]. List each day, week, pay period, or payday as the agency form requests. Attach more dated calculations if needed.

Other items included in the claim, if applicable:

☐ Unpaid tips: [DATES AND AMOUNT]
☐ Returned paychecks: [CHECK DATES, NUMBERS, AMOUNTS]
☐ Commissions: [PLAN, EARNING DATES, CALCULATION]
☐ Vacation or paid-time-off payout: [POLICY, HOURS, AMOUNT]
☐ Disputed deductions: [DATES, REASONS, AMOUNTS]
☐ Other unpaid wages: [EXPLANATION AND AMOUNT]

Wage advances or employer loans relevant to the calculation: [DETAILS]
Total unpaid wages claimed on the official form: $[AMOUNT]
When you requested payment and the employer's response: [DETAILS]

4. Records and filing check

☐ Gather pay stubs, time records, schedules, wage terms, and correspondence supporting each period.
☐ Attach copies of returned checks, a commission plan, or a vacation policy if those items support the claim; the official form specifically asks for them.
☐ Compare the claim dates with D.C. Code § 32-1308.01(a)-(b), which sets the administrative filing and recovery periods and includes notice and tolling provisions. Seek advice promptly if timing is disputed.
☐ Complete the current agency form's sections 1 through 7, including the sworn verification and any assistant certification that applies. Read its authorization to share the complaint with the employer before signing.
☐ Check the current agency page and form for delivery instructions. The page permits delivery, mail, or email; the PDF asks for a signed form and supporting copies by mail. Contact the Office of Wage-Hour at the number on the form if the signature or submission channel is unclear.
☐ Keep a copy of the signed official form, attachments, and proof of submission.

Official law: D.C. Code §§ 32-1302, 32-1303, and 32-1308.01.