Ariz. Admin. Code § R20-5-1002 - Forms

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

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

a. Claimant's name, mailing address, e-mail address, telephone number, and date of birth;

b. Employer's name, address, telephone number, and description of business;

c. Claimant's dates of employment, position, and pay;

d. The amount of the wages owed and the time period worked related to the unpaid wages; and

e. Claimant's signature or electronic signature and signature date.

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

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;

b. Claimant's dates of employment, position, and pay;

c. Whether claimant is owed any wages, and, if so, employer's reason for nonpayment; and

d. Employer's signature or electronic signature and signature date.

Notes

Ariz. Admin. Code § R20-5-1002

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 Section repealed; new Section made by final rulemaking at 12 A.A.R. 1416, effective June 4, 2006 (Supp. 06-2).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 at 27 A.A.R. 515, effective 5/14/2021.