Wage and Hour Intake Form

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: 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? 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.)?

If you have, please state to which agency or courts: When did you file? How did you hear about Tully Rinckey?