Wage and Hour Intake Form - Tully Rinckey PLLC

Are You Due or Owed Unpaid Wages?

If you are owed wages or any other monies by a current or former employer, allow our attorneys to help get what is owed to you. Please complete the form below to get started:

First name:

Last name:

Email:

Phone:

Employer / company name:

Number of employees:

Date of hire:

What is the nature of your claim?

Please explain why you believe your employer has not paid you properly:

Please describe the "who, what, when, where, why and how" of the incidents:

Rate of pay:

Per hour Per year

Number of hours normally worked per week:

Did You have an oral or written employment contract?

Yes No (Contract)

Are you employed pursuant to a union contract (CBA)?

Yes No (CBA)

What damages have you suffered to date?

Have you lost wages?

Yes No

If you answered Yes to the above question, $__ a month for __ months:

Benefits (E.g. bonus, commisisons, health, dental, retirement, etc.):

Yes No Other

Amount of unpaid overtime:

Number of missed, late, or short meal periods:

Have you filed any complaint with a federal or state agency or court concerning your employment or termination (including EDD, DFEH, EEOC, state court, etc.)?

Yes No

If you have, please state to which agency or courts:

When did you file?

How did you hear about Tully Rinckey?