Wage Security Fund Claim

If your employer went out of business without paying wages you are owed, you may be able to be paid up to $10,000 from Oregon's Wage Security Fund.

Fill out this claim form to begin the process. We'll follow up with you to get more information. Please keep any evidence you have, such as scans or photographs of pay stubs and time records. Before you get any payment, you will need to give us state and federal tax information.

If you have questions, you can call 971-673-0761 or email whdscreener@boli.state.or.us.

Your Information
Your Name * First Last
Email
Phone Number - ### - ### ####
Date of Birth / MM / DD YYYY
Your Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
When did you first start working for this employer? / MM / DD YYYY
When was your last work day? / MM / DD YYYY
Missing Wage Information
What are the dates you were not paid? List a date range, for example 01/02/2020 - 01/10/2020

List a date range, for example 01/02/2020 - 01/10/2020
Was your employment covered by a union contract?
Yes No I don't know
Have you taken action on this claim with an attorney, union, or in small claims court?
Yes No
This claim is for: (check all that apply)
Regular wages Overtime Sick time Prevailing wages for work performed on a public works project
If overtime, did your employer agree to pay overtime?
Yes No I don't know
What was your pay rate during the time you are missing wages? Please provide the amount and time period, such as "$15 per hour" or "$800 per week for 40 hours of work."
During the period of your claim, did you take any accrued paid time off, for which you were not paid? If so, explain.
What is the total amount you should have been paid for the date range you specified?
What is the total amount you were actually paid for the date range you specified?
How much do you believe your employer owes you?
Please describe the situation in your own words, including why you believe you are still owed wages and any reasons you were given for non-payment.
Have you asked your employer for these missing wages?
Yes No Other
Employer Information
Employer
Business Owner's Name
Type of Business
Employer's Phone Number
Employer Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Date your employer stopped doing business / MM / DD YYYY
Any additional contact information you have for your employer or the business owner (names, phone numbers, addresses, email addresses, etc)?
Has your employer moved out of its location(s)?
Yes No I don't know
Has your employer's telephone been disconnected?
Yes No I don't know
Are they still serving customers or employing workers?
Yes No I don't know
Have they filed for bankruptcy?
Yes No I don't know
Does your employer plan to reopen this business?
Yes No I don't know Other
Approximately how many employees work(ed) for this employer?
Did/does your employer have any other locations or businesses?
Yes No I don't know
If they do/did have other locations or businesses, please provide any information you have here (including contact information).
How did you find out that your employer was going out of business or had closed the business? When?
Do you know if your employer has any other assets that could be used to pay your wages? If yes, please elaborate.
Did your employer suggest you file this claim?
Yes No I don't know
Have you ever filed a wage claim before?
Yes No I don't know
Confidentiality

Pursuant to the state’s Public Records Law, the wage claim form is a public record which may be made available to a member of the public upon request. However, to the extent permitted by the law, BOLI will not disclose the claimant’s residential address, personal telephone numbers, and personal email address if you request that this information remain confidential.
I am submitting my address, telephone numbers, and email address in confidence and request that they not be disclosed.
Yes No
Assignment of Wages

In order for BOLI to pursue your wage security fund claim, you must "assign" the wages owed to us to investigate on your behalf. ~~~~~ I hereby assign in trust, to the Labor Commissioner of the State of Oregon, all wages, whether penalty or otherwise, due me from my previous employer, or any other persons legally responsible for the payment of my wages, along with any lien rights associated with such wages. I authorize the Labor Commissioner to file a priority proof of claim for those wages in any bankruptcy proceeding, and agree that any distribution on such claim will go first to the Labor Commissioner. By this statement, I authorize the Labor Commissioner to equitably adjust and compromise the amount of wages, whether penalty or otherwise, due me from my previous employer or other persons legally responsible for the payment of my wages. I acknowledge that the information I submit with this form may be used to determine my eligibility to receive benefits from the State of Oregon Wage Security Fund, and I state that this information is true and accurate to the best of my knowledge. I agree to immediately inform the Labor Commissioner if I obtain any payment from the employer or any third party for the wages claimed herein. And I agree to reimburse the Labor Commissioner in the amount of any wages I so obtain, but I need not reimburse the Labor Commissioner from wages or payments I obtain that are not the wages—whether penalty or otherwise—for which the Labor Commissioner is making payment to me from the Wage Security Fund. I agree to cooperate with the Labor Commissioner in any attempts he makes to recover moneys paid on my behalf from the Wage Security Fund, including but not limited to executing documents, such as lien claims, and providing truthful testimony associated with any legal proceeding.
Name (Electronic Signature) * First Last
Today's Date * / MM / DD YYYY

Wage Security Fund Claim

Wage Security Fund Claim

Your Information

Missing Wage Information

Employer Information

Confidentiality

Assignment of Wages