Employee Wage Claim Form

The Great Seal of the State of New Jersey

NEW JERSEY DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT

DIVISION OF WAGE AND HOUR COMPLIANCE

PO BOX 389

TRENTON, NEW JERSEY 08625-0389

Complainant Information
(First, Middle, Last)
If you wish to file anonymously, please enter "anonymous" as First and Last name
-- (xxx-xx-xxxx)
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
(333)333-3333
(333)333-3333

(** indicates a required field)

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