Section R20-5-1002. Forms

The following forms are available upon request from the Depart- ment or from the Industrial Commission’s Internet web site at www.ica.state.az.us:

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

a.        Claimant’s name, 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 claimed and whether the claimant requested payment of the wages from employer; and

e.        Claimant’s signature and signature date.

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

a.        Employer’s name, address, telephone number, and description of business;

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 and signature date.

Historical Note

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 Section repealed; new Section made by final rulemaking at 12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).