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Wage Evaluation Form

Please complete this form to find out if you qualify for Back Pay. The more information you provide, the better we can evaluate your claim.

First Name :
Last Name :
Email Address :
Phone Number :
Mobile Number :
Street Address :
City :
State :
Zip Code :
May we contact you by text message? :
YesNo
Job Title :
Name of company you work for :
Approximate number of employees with your job title or similar duties :
Employment Start Date. (If actual date is unknown, please select the first day of the month and the year you were hired) :
Employment End Date. (Leave blank if you are still employed with the same company. If actual date is unknown, please select the first day of the correct month & year) :
On average, how many hours per week do you work? (example: 45, 50, 61; not 50-60) :
How are you paid?
How much are you paid? dollars per (If paid a salary, give gross weekly, monthly, or yearly amount)

Are you paid time and a half if you work more than 40 hours a week? :
YesNo
How are you paid for hours over 40 per week?
Are you paid time and a half if you work more than 40 hours a week? :If you were paid for your overtime, are your bonuses, shift differential and/or other incentive pay included when your employer calculates your overtime pay rate? :
YesNoDon't Know
Please briefly describe your primary job duties and responsibilities.:
Do you supervise two or more full-time employees? :
YesNo
Can you hire or fire employees? :
YesNo
Do you make suggestions and recommendations as to the hiring, firing, or promotion of other employees that are/were given particular weight? :
YesNo
Do you discipline employees? :
YesNo
Are you given Comp Time instead of Overtime pay? :
YesNo
During the last 3 years, were you paid time and a half for overtime at your prior job(s)? :
YesNo
Additional Information and/or your comments.: