Labor

Fields marked with an asterisk are required and must be completed prior to clicking Pay Now.

Invoice Number

Claim Number *

#

Claimant First Name *

Claimant Last Name *

ST - Earned Pay Sick Time

Payment to Claimant

Civil Penalty

MW - Minimum Wage

Payment to Claimant

Civil Penalty

WC - Wage Claim

Payment to Claimant

CL - Youth Labor Civil Penalty

Civil Penalty

RT - Retaliation

Payment to Claimant

Civil Penalty

Earned Pay Sick Time Payment to Claimant Amount *

$

Earned Pay Sick Time Civil Penalty Amount *

$

Minimum Wage Payment to Claimant Amount *

$

Minimum Wage Civil Penalty Amount *

$

Wage Claim Payment to Claimant Amount *

$

Retaliation Civil Penalty Amount *

$

Retaliation Claimant Amount *

$

Youth Labor Civil Penalty Amount *

$

Customer Information

Organization *

First Name *

Last Name *

Email *

Phone Number *

Address

City

State

Zip

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