Texas Workforce Commission Labor Law Section Payday Documents to be Imaged Claim NO. 17-060494-5 User - Chapter: 1, Investigations 2. Special Hearings 3. Commission Review 4. Collections 5. Judicial Revicw Type of Document: Check Stubs/Payroll Recoxd Collecdon Documents Company Policy Manual Special Hearing Documents Commot/ Agreement on Pay Commission Appeal Documents Commission/Bonus Agzecment Judiuial Review Documents Aurhou'zation {or Deductions Other Descfipfionz Lbsaonw (0115) 1/29/2013 1:07 PM Texas Workforce Commission Labor Law Section Wag: Claim No: 17-060494-6 Claimant Name: Melinda Employer Account Numbetz- Investigator Name: -- Um ID: - Jurisdiction: Signed/Sworn: WC Date: 11-13-17 Infomiadon Search (check offitems reviewed) Payday System (Name Seaxch) Payday System (Employex Notes) Payday System (Bankruptcy)* 12] 505 (Filing History) IX sos (Pumer/Officetlnfommcion)* Texas Comptroller' As needed Amounts Claimed: Regular - Vacation Deducuons OverLime Sick Min. Wage Commission Holiday Othcr Bonus Severance Tomi Period in Dispute: Number of Hours DiSPuted: Employer Response Infomaiion Awarding to LL--Z): Employu Response Received? Claim Disputed? Claimant Paid? Check Received? Rate of Pay: Method of Payment, Check Cash Direct Deposit Other Bankruptcy: Case No. PACER Pxintouts Attached: (0715) 129nm km Texas Workforce Commission Labor Law Section Missing Facts: DATE INFORMATION USER ID 12-2047 Verify ifvaid, EEM 14948 Updmed ER In address uflieer liability EEM Name, SSN, and Address Vedficadons: Claimant's Legal Name: Melinda Brown Addie: - SSN Verified By . Melinda Brown Employe Address: Le Name: WELCO FEID or Numbe: of Employees: nd Verified By Al Wells, Owner Infomztion Search Printout Included: If yes, source: TX 305 Ifuo, why not Merhod olpayaaehe Verified By Conlacts 8: Infomed of Appeal Rights: Claimahr; Employer: DATE USER ID 12-20-17 INFO Called de lefia message at rdehlilyiug VM to return the call by 12-22-17. Need veri pal . Called ER a: --nd provided appeal righvs. Re nested a copy ufit and w. lhe mailed In new address srared CL was paid in cash for two wedrs No cash bur has wimesses. ER smed he will provide all documentation and information when wage elaim is received and reviewed; Timesheels and proof ofpaymem. CL letumed the call and revided appeal righls. Slated she was never paid in cash and has nolbeen paid. She did receive for gas and meals when traveling from Corpus Christi and San Antoni owever, nol know it was for wages oh the last work week was told she would be paid- weekly salary. Was told day before. Work week was Friday 10 Thursdays and pay days ah Friday. Her day alrwas Sunday. CL managed rhe huaihess, delegared the Walk In mare rhaa Iwo employees and The lasl week am added do her total wages owed, hawever, CL amended claim over phdue. Asked CL ilrhere was an agreemem [0 he wurked for the weekly salary and stated no. EEM 15:18 Relumed the call to CL at and asked about status on claim Informed a determination would be completed by 1-8-18. Asked CL to provide limeshee! for her last work week Provided email address. Called CL and asked she was hiredby and stated Al Wells. The work was delegated by both EEM (0715) 15an18 9:07 AM Texas Workforce Commission Labor Law Section Al Wells and Carolyn Wells. Called ER a-and led a VM to return the ealL Need to ask questions for economic reality teat. 1-9-18 Called CL at -- and "quested copy orcheck sruhs to show proororrate orpay. EEM Additionally, asked for proof of the last week worked which will/weakly salaryr Will email inrormation . CL mailed and stated she could not find the text message for the agreement ol-lweekly salary. 1.23.13 Called Ekal and lefi a VM to return the call. Need to uk questions for economic EEM reality test. Deadline 144-18. Law Violation: Codes: DATE INFORMATION USER ID l-s--lx Cl. is requesting inunpaid wages for work performed on 6-16-17 to 7-20-11 CL's pay EEM rate was an provide copy oftwo cheek stuhs showing pa rate ol/hr. 0n the last week worked 10-2047 to 10--25--17, her rape ofpliy was changed I (weekly salary. CL stated no set agreement on only the weekly salaxy. CL ammded the total wages owed to sheet provided 135 plus 48 for the last week worked. CL slaled she did reoe in cash fox meals and gas when she was traveling to and irorn location but did not know irthat was towards wages, Work week was Friday to Thursdays, oil on Sunday. l>ay day Friday. CL confirmed she has not heen paid and she received firom both Weils and Carolyn Wells CL identified Al Wells as the owner. ER was asked to provide information, however, failed to participate. Therefore, credence is given to the CL. However, hath parties agree with the in cash therefore, will he used as wages reoeived. Cl. worked 186 gross pay. From 10--2047 to 10-26-17 was 43 hrs. Under ELSA standards, CL worked as office manager and her duties were to manage the busiuus, delegate the work to more thantwo employees and produced the payroll. CL is exempt from an OT. Therefore, claimant worked a full week of 43 and owed her weekly salary of mm! is-- amss Pa Code Type Amount Code Type Amount Code Type Amount C040 01 - Code Type Amount Code Type Amount PenaltyAmonat Amounts Awarded Computations: DATE INFORMATION USER ID t-s--m 136MX_r-ssw- am Quarter/Year Quarter/Year Quarter/Year Quarter/Year 02/ 2017 4/ 20i7 (0715) mmuld Texas Workforce Commission Labor Law Section Employer Styling Justification Employer Account No: 1 Registered Entity: Y ® N ❑ Effective Date: 11-16-16 End Date: 7-25-17 FOCP: Y® N ❑ Sole Proprietorship/General Partnership: Y ❑ N® DATE INFORMATION 1-29-18 1-29-18 WELCO STEEL LLC., AND CAROLYN WELLS AND AL WELLS IN THEIR INDIVIDUAL I CAPACITY (ER and TX SOS verified) ER is currently in good standing and no economic reality test could be done. Penalty Warning Warranted: Y ❑ Y® Penalty Warranted: Worksheet Attached: Y® Y❑ Bond Warning Warranted: Justification: DATE INFORMATION 1-5-18 EEM EEM N® N❑ N❑ N® USER ID Prior violations with a warning Justification Corrected Order (Prior to Mailing/Scanning): DATE INFORMATION LL-5001/LL-3 (0715) USER ID 1/31/2018 9:07 AM EEM USERID Texas Workforce Commission Labor Law Section PAYDAY LAW BAD FAITH PENALTY ASSESSMENT EVALUATION FORM Penalty assessed against (check one): Employer claimant Bad faith Prong (check one): IXI Knowledge/Reckless disregard Factual Support for Bad Faith Finding: Was that a pain: violan'an wich a waning? Was ehece a pain: violan'on with a penalty? XI Plior claim number: 13--060148--0 Prior yiolanon became final: 11.25.13 Eadiest date wages were awed for payment on cuuent claim? 6-16-17 The dnimmt in this shim was not paid in accordance with the payday Law. The wages were earned $15.17 [0 740-17; 10>>20-17m10-26-17. Penalty Amount Factozs: 1. of the violation This employer conunnes to have daime filed againss chem for failure to pay wages. The findings of continued violnu'orls of the Texas Payday Law shows a Knowledgeable diseegaud for she Law. 2. History of previous violations The Laboc Law section has previously eeceived one or more wage claims that were detemfined to be in violation of ehe Texas Payday Law and were ruled in favor of the employees, The maiodcy of thew: wage claims were for nonpayment of wages eanied. 3. Amount necessaxy to deter fume violation: Due to the knowledgeable disregard to the Texas Payday Law and Rules, the full penniey amoune allowed by law should be The maximum penalty allowed by law is the lessec of the amount of wages owed or $1000.00 The ioial amDunt ofwages in quesuon i_ Thamfom ehe maximum penalty allowed by law is - 4. Other appropriate markets, including mitigation drcumstanccs letedb Review Conductedby: NW Mt Tide: Label: Law Invesfigutot Tide: Managpnae . Date: '[lammty 29, 2018 Date: [a (Mi 5) lrzmuls 1:07 PM LEV COPY DETERMINATION CODES: C0190 POI TEXAS WORKFORCE COMMISSION PRELIMINARY WAGE DETERMINATION ORDER Lahoi Law February I. 2018 PAGE I OF I PAGES CLAIMANT EMPLOYER STEEL LLC WELED STEEL LLE An investigation having been completed, the following order is entered pursuant to chapter 61 of the Texas Labor Code: FINDINGS AND EDNCLUS (INS Our investigation has determined that the claimant is entitled to for unpaid wages . Convincing evidence of employment has been provided for all or part of the peried claimed. It has been determined that the employer acted in bad faith with regard to this claim. ln addition to any wages determined due, the employer is also assessed an administrative penalty in the amount of ORDER The employer, WELCO STEEL is ORDERED to pay for the use and benefit of the claimant. MELINDA BRUWN and shall remit the gross or net amount disbursement payabIe to the Texas Warkfarce commission. In addition. being found in violation of Chapter 61 of the Texas Labor Code. the employer is assessed an administrative penalty in the amount of- which is to be remitted to the Texas Warkforce Commission. Assigned Representative: WMPENALTV (SEE REVERSE SIDE FOR ADDITIONAL INFORMATION) LL-ZSA (0310) Mm and an APPEALS ::YAu have the right to appeal this determination order. Your appeal must be in writing. It must be filed no later than 21 days from the date this determination order was mailed in order to preserve administrative appeal rights. If you fax your ,appeal, TWC must receive it no later than 21 days from the. date the determination was mailed. TWC will use the date : we. receive the fax to determine whether your appeal is timely. If you file your appeal by fax, you should retain your fax confUl.nation as proof of transmission. If neither party files a timely appeal, this determination order becomes the FINAL ORDER of the Commission. Appeals should be mailed or faxed to: Special Hearings ;T'exas Workforce Commission :101 East 15th Street Austin, Texas 78778-0001 .Fax#: 512-463-9318 Or You may appeal by TWC's online appeal form Go to www.texasworkforce.or2/uaydayappeal ADMINISTRATIVE LIEN . Sec. 61.081 of the Labor Code provides that "Afinal order of the Commission against an employer indebted to the state fo"r penalties or wages, unless timely appealed to a courL is a lien on all property belonging to the employer. The lien for an unpaid debt attaches at the time the order of the Commission becomes final:' PAYMENTS An employer who requests a. hearing to contest this determination should not send payment. Should your appeal decision affirm that wages are due, follow the payment instructions provided with the appeal decision. .An employer who does not request a hearing to contest the determination order shall 'pay the amount ordered to the Commission not later than the 21st day after the date of mailing of the order. An employer shall make a net payment amount (balance after valid deductions that are authorized by state or federal law, and by court orders; such as but not 7imited to federal income tax witholding, social security, and child support) payable to the Texas Workforce Commission. Payment to the Commission constitutes payment to the employee for all purposes. To ensure proper processing please "return the enclosed remittance slip, and deduction documentation with payment. You may contact the Commission for `clarification on valid deductions. PENALTY If the Commission determines that an employer acted in bad faith in not paying wages as required by this chapter, the Commission, in addition to ordering the payment of wages, may assess an administrative penalty against the employer. If the Commission determines that an employee acted in bad faith in bringing a wage claim, the Commission may assess =an administrative penalty against the employee. BOND . ,The Commission may require an employer to. deposit a bond if the employer is convicted of two violations of this cfiapter or a final order of theCommission against an employer for nonpayment of wages remains . unsatisfied after the tOth day after the date on which the time to appeal from that final order has expired and an appeal is not pending. Please provide the Labor Law Section written notification of any change in your address. Texas Workforce Commission Labor Law Section 101 East 15th Street Austin, Texas 78778-0001 1-800 832-WAGE (9243) -- Fax#: 512-936-3364 ^t.. o^nore info ination about the T^exas. Payday Law Law go to our web site atd ; , htt^n. //www.twc skfeaz:us/ iobseeke`rs/t exas-payaaY-^aw LL-25A-BK (0915) Po:e. STATE OF TEXAS TEXAS WORKFORCE Labor Law, Roam 114T "11 East 1501 Slreel Austin, Texas FILE CUPV DETERMINATION NBR: - WAGE CLAIM NBR: 17 DBDASA-E LLZSIJ (1215) STATE OF TEXAS TEXAS COMMISSION Labor Law. Room 124T East 15|h Sflefl Ausfin, Texas 7877841001 FILE EUPV STEEL: LLC DETERMINATION NER: WAGE CLAIM NBR: 17 050494-5 (1115) STATE OF TEXAS TEXAS Labnr LEVL Rom" 114T 1111 East 15th Street Austin, Texas FILE CDPV AL MELL51 REGISTERED AGENT DETERMINATIDN NBR: WAGE man: 17 060494-5 (1215) STATE DF TEXAS TEXAS WORKFORCE CDMMISS1UN Labor Law, Room 124T 1111 East |51h Street Auslin, Texas FILE CUPV NBR: WAGE CLAIM NBR: 17 060494-5 LL25D (1215) m. STATE OF TEXAS TEXAS WORKFORCE COMMISSION Labur Law, Roam 124T Ifl1 East 15th Smut Austin, Texas CAROLVN HELLX (1215) DETERMINATIUN NEH: WAEE CLAIM NBR: CUPV 17 "50454--6 STATE OF TEXAS TEXAS WORKFORCE COMMISSION Labor Law, Room 1241' 101 East 15m Street Austin, Texas FILE COPY IAIELCO LLC DETERMINATIUN NBR: WAGE ELAIM NBR: 17 neum-s (1215) STATE IJF TEXAS TEXAS WORKFORCE COMMISSION Labur Law, Room 1247 101 East 15m Street Austin, Texas FILE CDPV DETERMINATION NBR: WAEE CLAIM NBR: LLZSU (IZISI mm STATE DF TEXAS TEXAS WORKFORCE COMMISSION Labur Law, 114T 1fl1 East Street Auslill, Texas CAROLYN WELLS LLZED (1215) DETERMINATION NBR: WAGE CLAIM NBR: FILE CUFV -- 17 BENEFE um. (um From: Meh'nda Brawn-- Sent: Friday, January 5, 2018 AM Subject: Re: Hours for week of 10/20--10/25/17 Friday 10/20 a Monday 10/23 10 Tuesday 10/24 8 Wednesday 10/25 10 Thursday 10/26 12 on Fri,Jan 5, 2013 at 7:47 AM, Melinda Brawn-- wrote: Friday 10/20 8 onday 10/23 TEXAS WORKFORCE COMIVHSSION LABOR LAW SECTION 101 East 15m Succel, Room 514 Austin, Texas 78778 1780041323243 laborluwmn lovelrcs onse Lwc.smte.rx Welco Steel LLC c/o AI Wells Date: Decembet 20, 2017 RE: Wage No.2 17-060494-6 EMPLOYER INFORMATION REQUEST We need addiunnal informmion sensesning die WAGE CLAIM filed against our com an by the claim. ant(5): Melinda onwn. Please cull me as soon as possible. My direct line is Hui you inny use Lhe toll-fies line: In arn unavailable, please leave a message on my voice mil, including your name and dayume phone number. Please review wags cluiin and provide proof ofpayment; endoxsed check or direct deposit voucher number. My email address are 7 AM to 3:30 Pleas: cgmact me mithin days from the date of this letteri If I do not hear from you by that date, my determination will be based on the information uvajlabl: in the case 611; Thanks for your cooperation, Thanks for your coopetadon. Sincexcly, !a!ox an lnvesugator individuals mayreceive, review and correct inlannallan mat Two ballads sbaul ma individual by swam/lg gm mus arwrillng (0 TWO Opsn Remus, Rm. 255, 191 East 15'" SL, Austin, LL-6 (0617) inn/amen 2 u: 7 - m- heme: can be changed using me innumide1mm mamtxon) 4* Tamlweekly Home 110 Queslion #15 16 Commission at Bonus breakdown (AMP Muse include suppoxringinfomfion and mathematical roe WfioflW (Example: cuswmus/sales/nccoums (magma by) cummissiun/bmus commissio bonus due on . sxlc) Plus: include suppuning mange, web as log died: a! :ily--vu-u'ty flips, . ltyou need additional plane make copies. RECEIVED Wage Claim TEXAS WORKFORCE COMMISSION, LABOR LAW SECTION 101 EAST 15TH SHEET, AUSTIN, EMS mum-Isam a: TDD wan-7354939 (Hating 15124154075 Esta formulatio estai disponible en espafio] rms-Ewmrs my In: Name Soninl Sermrinumbu is optional, 5mm claim. fume monumeem yawn xD Quinn emu me undmd: we: El CLAIMANT WORMATION: Fnerame: mam ROANNA new we w: -- mu m- Damaifiinh . men-1 Ming: ham. ham Wfin' -- INFORMATXON AEOUT YOUR EMPLOYER: "Business Name Ownzt': Fink sz: (Incl: Owner: um Nana: WELCO LXC- DEA WELCO AL WELLS coumucmm AND EXPRESS METAL woxxs Owner. Businzss Adauee- Suit: cuy_ 5m: mm YOUR Wodx Damian (sum decss, City, Sme, zap): Employees Wodemu Employcr's Email or Web Am PLEASE COMPLETE THE Founwms mom INFORMATION: Whazwork did you pufoxm? _omcs MANAGER PAYROIL Beginningdate afanploymcm MAY 2017 Employment mm: with thi: employer: xu sun employed :1 Quit date Ram In: sepanfiam Whmwenc your xegulaxly scheduled TUESDAYREMOTE FROM coxpus cm: AND mommy THROUGH FRIDAY IN THE OFFICE IN SAN memo wax yuu me ofpzy? (Exunplu: salt-our, swab/mm, 52/5141)! HOUR Wham the listed woxk sdledulc? no Heep" day, a my: 1>>:ka olbe: a. Wesymueampensmenayeemm On! a Winn: (plus: 44 Were lh: claimed wzges and XE Yes El No 15mm ehe job Texas? I: Yes a Na 5. Wu: deducted xn Yes No (Page 4 of 7 This print header can be changed using the pxintHeader HTTII, tag - see the viewONE HTDff, manual for further information) 17. Additional Comments; ^ I UNDERSTAND THAT I MAY BE ASSESSED ANADMINISTRATIVE PENALTY IF THIS CLAIM IS FOUND TO BE BROUGHT IN BAD FAITS. To be considered valid, your Wage Claim must be completed below and signed as true under penalty ofncriurv. My name is _MELINDA _ROANNA BROWN my date of birth is (First) and my address is ,._ STATES (Stteet) (City) (State) (Zip Code) I declate under penalty ofperjurythattheforeoingistrue^an Executed in NUECUS i County,^ State of TE}LAS, f on the - Declarant Conphteel form, ingryirrer, armmrbau to the infioidiial iijnmrtiom mfitained in tbirjorm.rball be.rnt to the 17P/Clnborlaw Sedion,101 E. 151h St., Rm 124T, Aratny TX 78778-0001, (512J475-2670. InAruidrralrma,l renioe and rmiew mfonnation IbatT1PCmllatrabont tbe inrTioidrral by anai6ng to npnersmrrL(n^rmc:eate tx ar orwnting ta TIP/CO1arRemnfr,101 E 15tbSr,.Rm,266,Arutin,7X 787780001. OCEVED ,RdV 13 20 jmp,i.tLlkw 4 00 TEXAS WORKFORCE COMMISSIUN, LABOR LAW, 101 EAST 15TH STREET AUSTIN TEXAS 78773- DUDI NE 1 300-- 332 5243, HEARING PHONE 1- 300-- 735-- 2559, FAX 1-- 512 536~3364 LaborLaw. taps EMPLOYER RESPONSE TO WAGE CLAIM TE MAILED RECEIVE i/zz/i7 Claimant MELINDA BROWN DEC 1 I 2017 ldent cation an waee Chim No: LABOR LAW 1 AL lilELLs written res cnse should be filed no DEA lilELco LLC- DEA lilELco CONSTRUCTION -- Please use the above Wage Claim Number for all inquiries reglrding this wage claim, in accordance with the Texas Labor Code, chapter 61, the individual named above has filed a sworn wage claim for unpaid wages (copy enclosedl. This notice is an opportunity for you to respond. Failure to respond may result in a decision iavorable to the claimant ordering you to pay the amount claimed Please complete all sections oi the term are optional). By responding to this term. you are not tiling an appeal. Please submit relevant supporting documents such as true copies at related pay records, copies of canceled checks (from and back), employment agreements, contracts. signed authorizations. Job descriptions and handbooks or written policies relevant to the wages or benelits during the periodisl claimed. lntermatien sent may he made available to the claimant so dont send Erivnei information lslesl belcngi_ng to other emplo see This inves on will result in a Determination Order is sued to both parties. it you disagree With the Determination Order you receive, you may file an anneal by tollowmg the instructions on the reverse side or the Order. ll subsequent to Ihe wage claim being "led, you paid this ind' ual all of the claimed wages: complete the INFORMATION section and use question 16 to write the gross amount paid. the dateis) paid. and check numberisi. Enclose copies at endorsed checks (iron: and back), cash receipts, etc. EMPLOYER INFORMATION 1. What is your 1WD liEci Account Number? What is your Federal Tax in Number? 2. if other than the above address, to what address do you want correspondence mailed concerning this claim? 3. What is the lull legal name and address oi your business7 Name Address City State Zip 4. If business is a Sole Proprietorship, provide your iull legal name and 5. a) is your business a Partnerthipi )Yes 1 Na If yes] specifyr type at partnership (it: to Sc below and list the General Partners Names, Social Security Numbers Paene Numbers and Addresses (omit the - Seryica Dates ticidl. . bi IS your business Incorporated? ities Win it yes yporated what StaleY Charter Number to do business in Texas7 )Ves i )No List aeiaw Directors Officers' Names, Social Security Numbers, Addresses and Service Dues. c) Name Last 4 SSN Phenei Address Service Dates Name Last 4 digits SSN Address Service D3195 Name Last 4 digits SSN Phonei Address Service Dates Name Last 4 digits SSN Phone 2 Address Service Dates (If use addifinnzl sheels} s. is the business still operatingi )Ves i lNo Is the business in bankruptcy? )Yes i )No it in Bankruptcy: bankruptcy Filing Date Case No. Where Fiied Bankruptcy Attornei/s Name, Address and Phone Number 7. List any other businesses operated by the employer aL-a iuetvl (CONTINUED ON BACK) raw EMPLOYMENT AGREEMENT Job title and duties 8. Beginning date of claimant's employment Current employment status (complete one): Termination Date Quit Date Still employed 9,'Claitnant's Pay Schedule O Daily ( I Weekly O Bi-Weekly O Semi-Monthly'C)'.Nlonth(y.(J"'Other Claimant's rate of pay Scheduled Payday(s) Paid by ) Check () Cash ( ! ') Other 1 ) No ( Yes 10„Did you deduct Social Security and Withholding taxesfrom the claimant's paycheck(s)3 ONo ( )Don't Know 11: Was claimant's employment covered under.theovertime provisions of th^ Fa(r°Labor StandaYdS'Act7OYes Ifyou don't know: )Yes ( )No a. Does your business have an annual gross volume of sales or business equal to or greater than $500,000.00? ( b. Is your business or this employee engaged in interstate commerce, producing goods for interstate commerce, or otherwise working on goods or materials that have been moved in or produced for such commerce? Please explain WAGES CLAIMED The claimant provided a breakdown of the types of wages claimed. Please fill in the items below, giving the g'ross wage amounts you believe are currently due and owing to the claimant for each wage type claimed. Regular $ *Fringe benefits $Pay Deductions S Commissions $ Miscellaneous $ Paid Below Minimum Wage $ Overtime $Unpaid Bonus $ TOTAL UNPAID WAGES DUE TO THE CLAIMANT $ `The only fringe benefits that can be claimed are vacation pay, holiday pay, severance, sick leave or parental leave (these benefits cannot be claimed unlessprovided for in a written agreement ora written policy of the employer). )Yes" (. )No If yes, please attach a 12. Ifa fringe benefit was claimed, do you have awritten benefits policy/agreement? ( . , . " . . copy. Please attach a copy 18.If a bonus was claimed, was the bonus based on performance, or was it a gift? of the bonus agreement 14. If wages were deducted or withheld, did the claimant sign any documents authorizing the deduction7 ()Yes ()No If yes, please attach a copy of the authorization. 15. Are you aware of any agreement that exists that would preempt the Commission from ruling on this wage claim (e.g. arbitration, collective bargaining agreement, union contract, ERISA, Service Contract Act)7 If yes, please attach a copy of the agreement 16. The section below is for your explanation of why you believe the Wage Claim is incorrect Please be soecific. For instance, if you are disputing vacation pay, label your response "vacation pay", and indicate why you disagree with the cam. Use this space to explain copies of records (payroll, writtenpolicies, etc.) that you are submitting to support your response. If necessary use additional sheets, If subsequent to the wage claim being filed, you paid this individual all of the claimed wages: Complete the EMPLOYER INFORMATION section and use the space below to write the gross amount paid, the date(s) paid, and check number(s). Enclose copies of endorsed checks ( front and back), cash receipts, etc. "A Vr UNDER PENALTIES OF PERJURY, I HEREBY CERTIFY THAT THIS IS A COMPLETE, TRUE, AND ACCURATE STATEMENT OF THE FACTS RELATING TO THE CLAIM TO THE BEST OF MY KNOWLEDGE AND BELIEF Date Print Employer Representative's Name What is your direct Phone Number? ( ) Title Employer Representative's Signature EXT. Fax Number? ( 1 THIS DOCUMENT ISAN INQUIRY AHDISNOT REQUESTING PAYMENT. HOWEVER, IF YOUAGREE THAT WAGES ARE DUE, PAYMENT TO THE TEXAS WORKFORCE COMMISSION CONSTITUTES PAYMENT TO THEEMPLOYEEFOR ALL INTENTS AND PURPOSES. Completed forms, inquiries, or corrections to the individual Information contained in this form shall be sent to the TWC Labor Law Section, 101 E. 15th St., Austin, TX 78778-0001, (512) 475-2670. Individuals may receive and review information that TWC collects about the tndividual by emailing to open records0twe.state.tx.us or writing to TWC Open Records, 101 East 15th St., Austin, TX 78778-0001. roxM vnum(oam TEXAS tR!'t9Ry ^^^CE ^OMMiSS9M LABOR Lwwvv "-e- f' 101 E ^STd^ STREET ,,•-^" n A43ST^N TX 7Td7&-M U.S.POSTAGE$>PiTNEYsowEs . ziP7s7o, $000.67° n^nnn^wcco^Kfnli on onav RECBIVED DEC 112017 LABOR LAW 1 NZXZE 782 FE 1 0012/06/17 RETURN TO SENDER ATTEMPTED - NOT KNOWN UNABLE TO FORWARD ANK *0710-03156-22-38 SC: 78778 ^Illala^fit^ulll^efaai^i HiM IIaIIjIt1t,1IfilIejie}1 Illklf'IiI] . 4 Question #15 16 Commission or Bonus bxeakdown Pleaseinclude suppomng information and madiemauczl compumuon for Coimmssio pg Total weekly Hows 110 w! at bonus. (Example: :bonusdueonnsale) Please include suppofling information for mileage, such as log sheet: 01 dty>>w>>city alps. ii yau need additional please make copies. RECEIVED Wage Claim LABOR LAW 4 TEXAS WORKFORCE COMMISSION, LABOR LAW SECTION 101 EAST 15TH STREET, AUSTIN, TEXAS 7877$0001 szplionD Human)>> or 1-611-475-2670 in TDD 1-800-735-2989 (Hearing Impfiiled); Fax 1.517.475.3025 (PURSUANT TO m2) CHAPTER LABOR CODE) Esta fomuladn este disponible en espafiol PLEASE mm: CLEARLY 1N INK. Note: Social Sewrily Numbu is wpn'imd, bin {fling loincludeirwfl] delay pmmsing dam 1 Vim-rm: in mm mm in: English CLAIMANT INFORMATION: Starfish Quino quc TWC mic ma: [mun wmponlc-ncia en: Inglb Ewaflo| nonm' bminesi hws. INFORMATION ABOUT YOUR EMPLOYER: Finn Nam: MELINDA Middk: Last Name: BROWN Scciin'ly 4: Phone when you an benadmd during Alumni: Phone Mm you cm bzmdicd Date of Birth dunng Mimi mum mum EusinuanmfiIfiMm-panwdj Ownu'sFirsle-nc (1M: Ownar'sLasanmc: wcho DBA AL mus CONSTRUCTION AND muss METAL WORKS Ownu's Bushings Address_ Suite Stale: TEXAS Zl- voun Work Landon (Sum Adams, aiming, Zip): Work Phone Emplayar's 13--min Web Addxess: PLEASE COMPLETE THE FOLLOWING EMPLOYMENT INFORMATION: 1. What woxk did you pufomi? MANAGER I PAYROLL in: of :rnploymu-it Rum. [ex "minnow MAY 2017 Employment mm win. this employer: XI: sun emplaybd :1 Quit am am me your kguhxly sdimied paydiys? AND TUEDAY REMOTE FROM CORPUS cr-uusri AND WEDNESDAY THROUGH WAY IN THE OFFICE IN SAN ANTONIO Wham" yam mm ofpay? (Exunples: ss/hom, $1,000/mondi) "Lupine, sz/sq What W15 '11: ayccd woxk schedule? 40 3. W115 your compensation aglumcnl xn Oral 4, Were Ihe chimed wages camel in Texas? If not. was an job conmcted in Texas? 1 Were mxex deductcd fiomyour paycheck? HA. pix day, 3 Dayspexwln- Wfimn (please attach cnpyoihu Don't Know 6. Is the employer still in business? X❑ Yes What is the employer's home address and phone number? _UNKNOWN ❑ No ❑ Don't Know What is the name and phone number of your supervisor during the period claimed? -AL WELLS 210-2120586 7.: Is the employer in bankruptcy? ❑ Yes X❑ No ❑ Don't Know Are you in bankruptcy? ❑ Yes ❑ No If yes, what is the bankruptcy filing date?Chapter: 'CEIN",GL Case No: _ Where filed: _ NOV 1 3 2017 What is the bankruptcy attorney's name, address, and phone number? LMeRLAwa 8. If you are related to the employer, please state the relationship. 9. Did the employer give a reason for not paying you? If so, explain: -NEVER A REASON JUST THAT HE WOULD EVENTUALLY PAY US IF WE STUCK WITH HIM THAT BUSINESS WAS SLOW. I AM STILL EMPLOYED AND HE HAS PAID US SINCE HIS BUT I AM STILL OWED THIS BACK PAY. LL-1 (0417) Inv. No.621750 (Continued on Back) 10. Choose the type(s) of unpaid wages below that best describe your claim, and write the amount of unpaid wages, listing the gross amount of wages due. Note: You cannot file for rccovery of any type of expenses or reimburscxnent, since expenses and reimbursements arc not wages. Regular $ Overtime $^ Commissions $ *Fringe Benefits $^ Unpaid Bonus $ Pay Deductions $ Pay Below Minimum Wage $ TOTAL UNPAID WAGES CLAIMED $ "Tl^e atly fritrge Getrefrts that can be claimed are vacatiottpay, holitlaypay, severattcti, sick leave, paretrtalleave, paid time of, orpaid dgys off. pmvided for in a milten agreezneui or a wriitetr polrcy of t11e e»^b1 Jer. Tl^ese Leuefrts caiumt be daimed rarless 11. What was the scheduled payday(s) for these claimed wages? Date(s) Date(s) _6/30/17, 7/7/17, 7/14/17, 7/21/17, 7/2/17 12. If claiming regular, overtime, and/o.r minimum wage, what were the dates you worked for which you received no wages? I1'rom _6/16/17 to 7/20/17 Please explain how you determined the amount claimed and provide a breakdown of the days and hours worked. (Example: 20 hours regular pay at $5 per hour and 5 hours overtime pay at $7.50 per hour; or Example; 30 items at a piece rate of $.75 per item). If available, attach a copy of timecards or timesheets. Use the attachment located on the backside of the instructions to provide a breakdown of the days and hours worked. _ 13. If claiming commissions or bonus, what was the period in which the wages were earned? From _ to Are you aware of any agreement to pay commissions or bonus after termination? ❑ Yes ❑No Please explain how you determined the amount due. If available attach information to support your claim, such as written agreement, sales records, check stubs, etc. Use the attachment located on the backside of the instructions to provide a breakdown of commissions or bonus. 14. If claiming a covered fringe benefit, please explain which benefit(s) you are claiming and indicate how you determined the amount due: We must obtain a copy of a written policy or agreement providing a payment after separation, please attach a copy. Also attach evidence of the amount owed (hours left) such as check stubs or other documents. 15. If claiming deductions, did you sign any authorization for deductions other than regular payroll taxes? ❑ Yes X❑No ❑ Don't Know If yes, please explain (attach a copy). - 16. Are you aware of any agreement (such as arbitration, collective bargaining agreement, union contract, ERISA, Service Contract Act, etc.) that existed between you and the employer? ❑Yes X ❑No If yes, please attach a copy.; 17, Additional Cainmms: I UNDERSTAND THAT I MAY BE ASSESSED ANADMINISTRATIVE PENALTY IF THIS CLAIM IS FOUND TO BE BROUGHT IN BAD FAITH. To be wmidmd chi-um bdow and 5? ed mm under anal 'u . My Inn: is biannual; 7% my am ofhinh .s (month/day ear and my address Is ,and STA (Smut) (any) mp Code) (Cnumry) 1 d=clne undo: Funky ofpetiuty thud-Ac {om ingis mu: an 30/7 (Month) (Year) Exzcuced in Conn Stale Dcclatant CWlM/fimn, a: mum . Mum: "mm mix/m Elm/I En! la Vb: nVCubn mm, 101 a 15th It. Rm 1241, mm, IX 737mm 1' 475.2670. my main[aw/1m 9' [mm or mm to IWC Kmle'. 10! E, St, Km 25.; mm, 7377mm. . Wage Claim Form Attachment [ Question #14 Hours Worked Per Week. Breakdown Instructions: Enter the date of the starting day of the first wrkweek Enter the statt time for the first day on the time card o Enter the starting hour in the Hour column o Enter the minutes in the Min column o Enter AM or PM in the AM/PM column Example: Hyou started working at 8:30am enter; Hour Mn AM/PM 8 30 AM Enter the stop time for any break or lunch period in the Stop Time section; following the example above Enter the start time when returning to work from any break or lunch period in the Start Time 2 section Enter the ending time in the Quit Time section Enter the total number of hours worked for the date Enter the total number of hours worked for the entire workweek RECENED NOV 13 2017 LABOR LAW 4 Week 1 Start Time Stop Time MM/DD/YY Hour Min AM/PM Hour Min AM/PM Hour Ex: 1.2/01/16 8 00 AM 12 00 PM 1 6/16/17 8 6119117 8 612a117 8 6121/17 8 6/22/17 8 00 1 AM 12 00 1 PM 1 12 00 I PM 1 Min r1M/PM 00 Hour Min AM/PM 5 00 PM PM 00 1 PM Hours Worked Quit Time Start Time 2 5 00 1 PM MM/DD/YY 10 4 00 1 AM 00 1 AM 12 00 1 PM 4 1 00 1 PM 5 PM 10 00 1 PM 10 TotaE weekly Hours Week 2 8 Start Time Stop Time Start Time 2 Quit Time 38 Hours Worked Hour Min AM/PM Hour Min AM/PM Hour Min AM/PM Hour Min AM/PM 6123117 8 00 PM 1 00 PM 5 00 PM 8 00 12 12 00 6126117 AM AM 00 PM 4 00 AM 12 00 PM 4 12 00 PM 12 00 PM 6127/17 6128/17 8 00 6129/17 8 00 1 AM AM 8 00 AM 12 00 PM PM 6/30/17 10 00 5 00 PM 10 1 00 1 PM 5 00 PM 10 1 00 1 PM 5 00 PM 10 00 AM 12 00 7/5/17 8 00 AM 12 00 PM 00 PM 716117 8 00 12 12 12 12 12 00 1 PM 00 PM 00 PM 00 PM 4 00 PM 4 00 PM 1 00 1 PM 12 00 PM 1 00 AM 12 00 PM 1 00 713117 7110117 8 7/11/17 8 7112117 8 7113117 8 AM 00 1 AM 00 AM 00 AM 00 AM 00 AM 7l14117 8 00 7/17/17 8 00 AM 12 00 PM 7/17/17 8 00 AM 12 00 PM 7/19/17 8 00 AM 12 00 PM 71 20117 8 00 AM 12 00 PM 717117 ©c--( o^vYL. 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