Wage Dispute Small Claims Submission Form
Claimant Name
Phone Number
Email Address
Address
Employer Name
Employer Address
Employer Phone
Employer Email
Employment Start Date
Employment End Date
Job Title
Type of Employment
Full-time
Part-time
Temporary
Contract
Amount of Unpaid Wages ($)
Period Unpaid (Dates/Description)
Description of Dispute
Steps Taken to Resolve This Dispute
Supporting Documents List
Signature
Date Submitted