1. 1. Wage claim. When making a claim, a claimant shall provide the following information to the Department:

   1. a. Claimant’s name, mailing address, e-mail address, telephone number, and date of birth;
   2. b. Employer’s name, address, telephone number, and description of business;
   3. c. Claimant’s dates of employment, position, and pay;
   4. d. The amount of the wages owed and the time period worked related to the unpaid wages; and
   5. e. Claimant’s signature or electronic signature and signature date.

2. 2. Employer response. The employer responding to a claim shall provide the following information to the Department:

   1. a. Employer’s legal name, including any trade names, legal domicile state, address, telephone number, description of business, and an e-mail address for the designated representative of employer;
   2. b. Claimant’s dates of employment, position, and pay;
   3. c. Whether claimant is owed any wages, and, if so, employer’s reason for nonpayment; and
   4. d. Employer’s signature or electronic signature and signature date.

The following forms are available upon request from the Department or from the Industrial Commission of Arizona’s website at www.azica.gov:

Historical Note

Adopted effective January 26, 1988 (Supp. 88-1). R20-5-1002 recodified from R4-13-1002 (Supp. 95-1). Section repealed; new Section made by final rulemaking at 12 A.A.R. 1416, effective June 4, 2006 (Supp. 06-2). Amended by final rulemaking 27 A.A.R. 515, effective May 14, 2021 (Supp. 21-1).