 |
 |
 |
 |
|||||||||||
 |
||||||||||||||
|
 |
 |
||||||||||||
|
Wage and Hour Form Wage Claim Questionaire To have Goyette & Associates review your potential wage claim, print this form, fill out the information below, then fax it to us at 916-851-1995. |
||||||||||||||
 |
 |
Name: First: ................................................................... Last: ................................................................... Home Phone Number: ...................................... Work Phone Number: ....................................... Cell Phone Number: ......................................... Email Address: .................................................. Address: ............................................................ ............................................................................ ............................................................................ Employer with whom you have a wage dispute: ................................................................................. Employers Address: ............................................................................. ............................................................................. ............................................................................. Employers Phone Number: ................................................... Dates you worked for this employer: Start Date/Year: ..................................................................... End Date/Year: ..................................................................... Total number of weeks worked (not counting periods of no work): .................................. What was / is your work schedule for this employer?: ....................................................... ............................................................................................................................................. What was / is your Title as an employee for this employer?: ............................................. ............................................................................................................................................. Describe your duties for this employer: ............................................................................. ............................................................................................................................................ ............................................................................................................................................ Approximately how many similarly situated employees (employees who held the same title and did the same work as you) worked for this employer at the time you worked there?: ............................................................................................................................................ What is, or was, your rate of pay with this employer?: ...................................................... Describe further if necessary: ............................................................................................. ............................................................................................................................................ What company documents, if any, describe this pay schedule?: ......................................... ............................................................................................................................................ On average, what was your compensation per week?: $ per week: .................................. How often were you paid (weekly/monthly/other)?: ............................................................ On average, how many hours did you work per day AND per week to obtain this compensation?: Number of hours : ........................... Were you ever paid overtime at 1.5 times your normal rate of pay for hours worked in excess of
40 hours per week OR in excess of eight hours per day?: What written evidence do you have to document the hours per day or per week that you worked?: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ If there is no written evidence of hours worked, OR aside from any such evidence, CAN present or past workers testify that hours in excess of 8 per day or 40 per week were worked?: ............................................................................................................................................ Can present or past workers tesify that supervisors KNEW that hours above 8 per day or 40 per week were being worked?: ............................................................................................................................................ Did any supervisors ORDER a volume of work per week such that work in excess of 8 hours per day or 40 hours per week was unavoidable?: ............................................................................................................................................ Did you typically recieve two ten minute breaks AND one 30 minute meal period (free from work duties) per day?: ............................................................................................................................................ Describe your supervisory responsibility for your position: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ What is the highest level of education you have recieved?: ............................................................................................................................................
............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Were you supervised closely and frequently? Describe: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Did you make significant decisions independently (without supervision or approval of a supervisor) and often? Describe: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ Are there any other factors/issues relevant to your potential wage claim ? Describe: ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ ............................................................................................................................................ PLEASE give the names & contact numbers for any individuals you know who still work for this employer performing the same or similar work you performed: 1. ............................................................................................................................................ 2. ............................................................................................................................................ 3. ............................................................................................................................................ 4. ............................................................................................................................................
Please note that, by submitting this form, no Attorney-Client relationship is formed with the law firm of Goyette & Assoicates, Inc.. Also please note that no Attorney-Client relationship is formed with Goyette & Associates, Inc. unless, after evaluating your potential wage claim, the firm determines that legal action based on the claim is feasible, and that the firm wishes to represent you in such claim, and such representation is specifically agreed to in writing between you and Goyette & Associates. |
||||||||||||
 |
||||||||||||||
|
||||||||||||||
