Free California Labor Commission Initial Report (DLSE Form 1) - PDF Form Download
California Labor Commission Initial Report DLSE Form 1 is intended to facilitate filing a claim to recover the wages from the employer. Submit duly completed DLSE form 1 to the office of Labor Commissioner, State Of California for its processing.
You may need to fill and submit DLSE FORM 205 and DLSE Form 55 along with this form. You must type or print all particulars and mark your choices in the boxes for legibility. This form is however not suitable for filing a public works project claim and you need PW-1 form in such case. DLSE Form 1 is divided in 7 parts and the last page is reserved for office use. Your inputs are not required on the last page.
Begin filing the Initial Report or Claim by answering preliminary questions starting with the selection of whether a retaliation complaint is filed. Furnish date of complaint if you select yes. Attach a copy of the Collective Bargaining Agreement during the instance of the union contract covering the employment. Select one of three choices to confirm if other employees are filing wage claims too.
Proceed to Part 1 and answer Yes, if you need an interpreter and not otherwise in 5a. Mention the language in 5b if you select yes in 5a. Specify advocate’s name, firm name, phone number, and mailing address in line 6. Continue to Part 2 and furnish your first and last name, home and other phone number, birth date, and mailing address.
Part 3 of DLSE form 1 seeks input about the employer like employer/business name/s, license plate number of employer’s motor vehicle, phone number, and address. Provide the address of the place you worked at if different from address in line 16. Insert first and last name and title/position of the person in charge. Specify type of business in line 20, nature of work in 21, and total number of employees in 22. Select one from three options in 23 to state whether the employer is still in business. Select the type of employer in 24 by marking the right box.
Print your name on the foremost line of page 2. Continue to Part 4 by providing inputs like date of hire in 25, select the right status in 26, and specify the particulars if you select others, select the right answers about the notice in 27a and 27b. Make your selections carefully in 27b and provide date if you select Yes. Insert date of receiving final payment upon discharge if you mark yes in 28 or select no otherwise. Select the mode of payment in 29a and specify if any paycheck dishonored in 29b.
Part 5 requires specifying if your hours of work are same or not in 30. Furnish the particulars of your work hours in the prescribed format in 31. Fill in the details for all working days of a week starting your day with Monday. Continue to Part 6, Payment Of Wages. Select the right options in 32 if you were paid a fixed wage in spite of the work hours/days and select the schedule for paid and promised fixed wage. Select no when not applicable. Proceed to 33a if you were an hourly employee and specify the particulars in 33a and 33b as applicable. Select if you were paid by piece rate or commission in 34 and 35 respectively.
Part 7 has 11 boxes for selection. Mark all that apply and furnish particulars in front of the selection. Add all claimed/earned amounts and subtract amount paid from the total to arrive to a grand total owed. Select the boxes in 37 for claiming waiting time penalties and/or penalties for dishonored checks.
Complete form DLSE 1 with your signature and insert date along with your printed name in the respective spaces. Your inputs are not required on the last page as it is reserved for the office use.