Documents to be Imaged Claim No. 13-060148-0 User ID - Chapter: 11 Investigations 2. Special Hearings 3. Commission Review 4. Collections 5. Judicial Review Type of Document: Check Stubs/Payroll Record Collection Documents Company Policy Manual Special Hearing Documents Contract/Agreement on Pay Commission Appeal Documents Commission/Bonus Agreement Judicial Review Documents Authorization for Deductions Other Description: LL75001 (0506) 10/31/2013 2:23 PM Wage Claim No: 13-060148-0 Texas Workforce Commission Labor Law Section INVESTIGATION DOCUMENTATION WORKSHEET Claimant Name: CARLOS OCHOA Employer Account Numbe Investigator Name: User ID: Jurisdiction: Signed/Sworn: WC Posnnark/'Faxed/Received: 08/29/ 13 Information Search: (cheek nmu-ms rc'viuwcdp Payday System (Name Search) Payday System (Employer Notes) Payday System (Bankruptcy) Texas Comptroller* Amounts Claimed: Regilar - Vacation Deductions Overtime Sick Min: Wage Commission Holiday Other Bonus Severance Total Period in Dispute: 07/22/13 to 07/28/13 Number of Hours Disputed: fl Employer Response Information; Employer Response Received? Claim Disputed? YI Claimant Paid? YI i Check Received? Rate of Pay:- (According to Employer) Method of Payment: Check Cash Direct Deposit Other Bankruptcy: Case No. PACER Printouts LL-3 (1012) Primed: 10/31/2013 2:12:53 PM Texas Workfurce Commission Labor Law Section INVESTIGATION DOCUMENTATION WORKSHEET Wage Claim No: 13--060148-0 Name, SSN, and Address Verifications: Claimant's Le a1 Name' Carlos A. Ochoa Addres SN Verified By: Claimant Employer's Legal Name: Address: EID or SSN: Number of Employees: Verified By: Information Search Printout Included: Y: N: If yes, source: If 110, Why not: Method of Payment: Check Verified By: Claimant I'm-Investigation Information: DATE INFORMATION USER ID 10/18/13 The claimant is requesting- in regular wages. AWX The employer has rebuned, stating the claimant has already been _paid. Claimant Employer Contacted Informed of Appeal Rights: Claimant: Employer: DATE INFORMATION USER ID 10/3 1/13 The claimant was contacted using telephone number AWX and stated: They paid me. They paid me around ey pm me three days afier I filed the Wage Claim. The claimant has been informed of his Appeal Righls. Law Violation: LL-3A (1012) Printed: 10/31/2013 2.13 PM Texas Workforce Commission Labor Law Section INVESTIGATION DOCUMENTATION WORKSHEET RulinglJustifcation/Determination Codes: DATE 10/31/13 10/31/13 INFORMATION USER ID The claimant was paid by the employer an amount with which he is satisfied; however, the employer violated the Texas Payday Law by a in the claimant later than his normal payday of 08/05/13. E124 type 1 /'E141 Amounts Awarded Computations: DATE INFORMATION 10/31/13 The claimant had originally requested in addition to a bank feed due to an initial bounced check; however, the claimant has stated that he was paid around and this is an amount with which he is satisfied. Quarter / Year 03/2013 $: Quarter / Year Quarter / Year AWX AWX USER ID AWX Quarter / Year $: Employer Styling Justification: Employer Account No: Registered Entity: Y: X N: FOCP: Y: N: X Effective Date: End Date: Sole Proprietorship/General Partnership: Y: N: X DATE INFORMATION USER ID 10/18/13 The employer styling of WELCO STEEL, LLC is justified by SOS and AWX EMF. Penalty Warning: Bond Warning: Penalty: Worksheet Attached: Justification: DATE LL-3A (1012) Warranted: Y: X Warranted: Y: Warranted: Y: Y:. N: N: X N: X N: X INFORMATION USER ID Printecl:; 10/31I2013 2:23 PM FILE COPY . DETERMINATION CODES: EIZA TEXAS WORKFORCE COMMISSION PRELIMINARY WAGE DETERMINATION ORDER Labor Law November 5, 2013 PAGE 1 0F 1 PAGES CLAIMANT EMPLOYER WELCD :5 Mg "1.3 ELENA--D-- WELCO STEEL. LLC An investigation having been completed, the following order is entered pursuant to chapter 61 of the Texas Labor Code: FINDINGS AND CONCLUSIONS The claimant is not entitled ta unpaid wages . The empIDyer has paid this amaunt. Payment was made after the wage ciaim was filed, but before this determination order was issued. it has been determined that the employer violated the provisions of the Texas Payday Law when the claimant's earned wages were not paid in accordance with the law. if it is determined that an employer has acted in bad faith. the Commission may assess an administrative penalty for failure to pay wages as required by law. In this case no penalty is assessed. ORDER Based on the FINDINGS AND CONCLUSIONS shown above, the wage claim fiied by CARLOS A OCHOA and naming the emponer WELCD STEEL, LLC is dismissed. (SEE REVERSE SIDE FOR ADDITIONAL INFORMATION) (nasal APPEALS You 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 confirmation 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 Texas 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.or g/jRUda.vappeal 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 LL-250-BK (0613) PP250R TEXAS COMMISSION, LABDR LAW, 15TH STREET, AUSTIN. TEXAS 78778-0001 NO I PHONE TEXAS 1--dao--asz--524: iHEARii't'a IMPAIRED 17800773572985). FAX 175124354364 OUT or STATE 1751274757157u SO EMPLOYER RESPONSE TO WAGE CLAIM 3 DATE 4 09/18/13 Claimant CARLOS A DCHDA ide cation Nbr: Wage claim No: '3 oeoMB-D AL written ouid be filed no STEEL ner an iourreen i4 da atter the on this notice was mailed see postmark. Please use the above Wade Claim Number far all inquiries regarding this wade claim. in accordance wuh the Texas Labor Code, chapter 6i, the individual named above has itied a sworn wade claim for unpaid wages (copy enclosed). This notioe is an opportunity for you to respond. Failure to respond may result in a doc ion favorable to the cleimant ordering you to pay the amount claimed. iease.coniplete oi the 4cm (SSN's are optional). By responding to this form. you are not filing an app Please su mit relevant supporting documents such as true copies oi related pay records, copies oi canceled checks (iront and back). employment agreement; contracts signed dmharixmtons, job descriptions. and handbooks or written poi ies relevant to the wages or beneiits during the periodisl claimed Inicrniaticin sent may be made available to the claimant so don't send private lniormation isSN'si belonging to other emplo see. This investigation will result in a Determination Order being issued to both parties. If you disagree With the Determination Order you receive, you may the an aopeai by iollowinp the instructions on the reverse side of the Order. Ii subsequent to the wage claim bail-t9 tiled, you paid this individual all of the ole med wages: Complete the EMPLOVER INFORMATION section and use question 16 to write die gross amount paid the dateis) paid. and check numberis), Enclose copies oi endorsed checis liront end hack), cash receipts, etc. EMPLOYER INFORMATION 2. ll other then the above address, to what address do you want correspondence mailed concerning this claim? 1. What is your rrEci Account Number? 3. What is the tuil legal name and address at your business? Name Address city State Zip Ii business is a Sole Proprietorship, pro your full legal name and SSN 5. a) is your business a Partnership? lVes (74 No yes, spec-iv type oi partnership Go to be below and list the Geneial Famers' Names, Social Security Numbers. Phone Numbers and Addresses (omit the Service Dates field]. bi is your business incorporated? (fives iNo If yes, incorporated in what stake? Corporate Charter Number uu ied to do business in Texas? (Wes )No List below Directors' 1 Names, Social Security Numbers. Addresses and notes. cl Name Phone( 1 Address Name SSN Phonet Address Service Dates Name SSN Phune( Address Service Data: flax" BE Name SSN Phone 3 Address Service Dates Be' "1 (if necessary, use additional sheets) s. is the business still operating? VWes No is the business in bankruptcy? 1 Was )No it in Bankruptcy: Bankruptcy Filing Date Case No. Where Filed Bankruptcy Attorney's Name. Address and Phone Number 7. List any other businesses operated by the employer no (nJm) icomiuuso 0N eacxi In: AGREEMENT. .. 8. Beginning date of claimllt's employment Q1 ZZ Job title and duties Ciarent employment status (complete one): Still employed Ctuit Date--gu--Temllnation 5, Claimants Fay Scnedule Daily Weekly i [SI--Weekly i) Semi-Montniy i Omar Seneouled Fayday(s) Wang; 5 Claimant's rate ot by )ci Cnectt i Cash i other it). Did you deduct Social Security and Witnnoidlng taxes trom tne claimant's paycheckiS)? yes No ll.Was claimant's employment covered under tne overtime provisions oi tne Fair Labor Standards lyes )No iflaon't Know it you dorrt know: WM Oi. iO'l'l manger-zy- a. DoeS your business nave an annual gross volume of sales or business equal to or greater tnan $500,000.00? )yes )No Is your business or this employee engaged in interstate commerce. producing goods tor interstate commerce. or otherwise working on goods or materials that have been moved in or produced tor sucn commerce? Please explain WAGES CLAIMED The claimant provided a breakdown oi the types of wages claimed Please fill in the items below, giving the gross wage amounts you believe are currently due and owing to the claimant tor each wage type claimed Regular 6 Commissions benefits 5 Pay Deductions Overtime 5-- Unpaid Bonus 5 Paid Below Minimum wage 5 Miscellaneous 5 TOTAL UNPAID WAGES nus To THE CLAIMANT a The only tringe benetits that can be claimed are vacation pay. holiday pay. erance sick leave or parental leave (these benefits cannot be claimed unless provided tor in a written agreement or a written po cy of tbe employer). it a fringe benefit was claimed, do you have a written benefits policy/agreement? Wes )No it yes, please attach a copy. la." a bonus was claimed. was tne bonus based on performance. or was it a gift? the bonus agreement. l4." Wages were dedicted or withheld did tne claimant sign any documents authorizing the deduction? i We: )No if yes, please attach a copy of tne authorization. is. Are you aware oi any agreement that exists that would preempt the Commission from ruling on wage Claim (eg. arbitradon. collective bargaining agreement. union contract ERISA. Service Contract Act)? it yes. please attach a copy oi the Igleemem. to The section below is lor you explanation ot why you believe tne Wage Claim is incorrect. glease be Smcificfor instance. if you are disputing vacation pay. label your response "vacation ay'. and indcate my you disagree the claim. Use this space to explain copies of records (payroll. written policies. etc. tnat you are submitting to support your response If necessary use additional sneets. kdalfm yafl'ari an NS Him/e. a, can; of} Ham: Clea/c1 Nun/Jean): Please attach a copy oi I 73s? UNDER PENALTIES oF PEldulV, HERESV cERTva THAT THIS IS A TRUE, AND or THE FACTS RELATING Tn THE CLAIM To BEST or My KNWLEDGE AND WW Prim Empl lly a Emplu signetu rt IS Au xuouxnv AND 15 fl HauEl/En, IF you AGREE THAT WAGES ARE WE, PAYMENT TD THE TEXAS wunKFuncE CONSTITUTES PAYMENT Tu THE so: ALL AND oomala .n unlaa, pr curl-Ell": to in. individual inlemtatlnn sent nao in tnia lonn analt ba aant to we L-buf Sunlun. tot err. Sm, lm. tzar, Austin, 7m vpui. lsto) -zsvu. individuals they no review lnturmatlan mar (all-cu Ibnul tn lnolvldual by to uEln esraaetwcat onus at writing to naooroa. tut east 15m st, nni, m, Auatln. rx "we-uni. :57 sfmn. cam am; mmam Mm Pay Pom mam-7r RECEIVED . ocfin 2013 LABORLAWL . SAN Amcmm "m 5 . 'mfi 0153mm w' acre. mm .014 3 onxv 'Twc Labor bowJ urge?" St RECEIVED 7" ucronma LABOR LAW 1 73773,; 'Texas Workforce Commission Labor Law Section Payday Documents to be Imaged t &-0^0149 " -0 Claim No. User ID Date Chapter: I, Investigations 0 2, Special"Hearings _ [j -.'- 3, Commission Review a 4, Collections ' ❑ 5, Judicial Review n Intake: LL-2 Employer Association [^^ Acct ___:rype of Document: Check Stubs/Payroll Record Company Policy Manual Contract/Agreement on Pay Commission/Bonus Agreement Authorization for Deductions [Q Collection Documents [] Special Hearing Documents [Q Commission Appeal Documents Judicial Review Documents El 0 Other Description: i.L-JQQi (0112) C.lUsenlcavazvioU7asktoptVictori4Cavazaalt,L-3001(0112),doa TEXAS WURKFURDE CUMMISSIDN, LABOR LAW, EAST 15TH STREET. AUSTIN. TEXAS PHONE IN TEXAS 1--suu-s'32--szdz (HEARING IMPAIHED 1-500-785-2989), FAX 1--512-536--3354 OUT OF 1--512--475--2510 EMPLOYER RESPONSE TO WAGE CLAIM DATEIMAILED Claiman CARLOS A OEHOA Identificuiiall Nbr: Wage No: 13 0 AL DEA llIELco CONSTRUCTION SERVICES STEEL W's" '95 "0 ee nIourtee I ate this nor-ca was mailed see postmark). or Please use the above wade Claim Number for all lnqulries regarding ttiis wage claim In accordance wlui the Texas Labor Code, 61, tne indi dual named above nas liled a sworn wags claim Ior unpaid wages (copy enclosed). This notice is an opportunity tor you to respond Failure lo respond may result in a dec Iaverable lo claimant ordering you to pay me amount claimed. Please complete all sections ol the term (SSN's ere optional). By responding to itlls icrm. you are not tiling an appeal. Please submit relevant supporting documents such as true oopies or related pay records copies of canceled checks mom and back). employment agreements contracts, siened autnorisations job descriptions and handbooks or written policies relevant to the wages or benefits during ine periodls) claimed Inicrmari sent may be made available to the claimant so don't send rivole intornmlon belon in te oltier em Io ees. inis in sliestlon will result in a Elng issued pour parties. I you isagree witn tne eterminetion Or or you receive, you may Iile an appeal by tellowmg tire lnsiructlons on "13 reverse side o? the order, It subsequent In true wagn claim being liied, you paid this indiv ull all of the claimed wages: Complete ttie EMPLOYER INFORMATION section and use question is to write are gross amount par . ills dalels) paid and snack numberlsi. Enclose copies el endorsed checks Ilront and back), cash receipls, etc. EMFLOVER INFORMATION I. wtial Is your rrEc) Account Number? What is your Federal lax ID Number? 2. If oltier lnen tne above address, to what address do you want correspondence mailed concerning Ihis claim? z. wnat is tne lull legal name and address of your business? Name Address city A. if business is a Sole Proprietorship, provide your full legal name and state ZIP E. a) Is your busi ass a Partnership? I )Vss I No It yes, specity type oI perinerstii'p Go to is below and list we Generel Parmers' Names. Social security Numbers, Phone Numbers and Addresses (omit the Servloo Dates fieldil b) Is your business Incorporated? I Was )No If yes, incorporated in wtiat state? Corporate charter Number -- uualilled to do business In Texas? I )Ves I we List below Directers' I oliicers' Names, Social Securily Numbers, Addresses and Service Dates Phone! Serylce Dates SSN FhoneI Dates Phone( Service Dates SSN Ehone( Service Dales (If necessary use additional sheets) a. Is the buslness slilI operating? I Was I )No Is tne business in Eanltruplcy? I )Yes I No If ln Bankruptuw Eankruplcy 9 Date Case No. wnere Filed Bankruptcy Attorneys Name, Address and Phone Number 7d List any other businesses operated by the employer LL72 (Mm) icomiuuap on aaciu vaml y EMPLOYMENT AGREEMENT 8. Beginning date of claimant's employment Current employment status (complete one): Job title and duties Termination Date Quit Date Still employed 9. Claimant's Pay Schedule O Daily O Weekly O Bi-Weekly O Semi-Monthly-4 ) Monthly O Other Claimant's rate of pay Scheduled Payday(s) ) Other Paid by ( ) Check ( ) Cash ( ) Yes 10. Did you deduct Social Security and Withholding taxes from the claimant's paycheck(s)? ( ) No ( Was claimant's employment covered under the overtime provisions of the Fair Labor Standards Act? ( )Yes {)No ()Don't Know 11. If you don't know: )No )Yes ( 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 gross wage amounts you believe are currently due and owing to the claimant for each wage type claimed. $ Commissions $ *Fringe benefits $ Pay Deductions $ Overtime $ Unpaid Bonus $ Paid Below Minimum Wage $ Miscellaneous $ Regular 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 unless provided for in a written agreement or a written policy of the employer). 12. If a fringe benefit was claimed, do you have a written benefits policy/agreement? ( )Yes ( )No If yes, please attach a copy. Please attach a copy of 13. If a bonus was claimed, was the bonus based on performance, or was it a gift? the bonus agreement. 14. If wages were deducted or withheld, did the claimant sign any documents authorizing the deduction? ()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)? 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 specific. For instance, if you are disputing vacation pay, label your response "vacation pay", and indicate why you disagree with the claim, Use this space to explain copies of records (payroll, written policies, etc.) that you are submitting to support your response. If necessary use additional sheets. UNDER PENALTIES OF PI~RJURY, 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? Employer Representative's Signature EXT. Title Fax Number? THIS DaCUMENT IS AN INQUIRY AND IS NOT REQUESTING PAYMENT. HOWEVER, IF YOU AGREE THAT WAGES ARE DUE, PAYMENT TO THE TEXAS WORKFORCE COMMISSION CONSTITUTES PAYMENT TO THE EMPLOYEE FOR ALL INTENTS AND.PURPOSES. Completed forms, Inquiries, or corrections to the individual lnformation contained in this form shall be sent to the TWC Labor Law Section, 101 E. 15th St., Rm. 124T, Austin, TX 78778-0001; ( 512) 475-2670. Individuals may receive and review information that TWC collects about the individual by emailing to open.records@twc.state.tx.us or writing to TWC Open Records; 101 East 15th St., Rm. 266,. Austin, TX 78778-001. FDRM PQLL28(090) REMITTANCE SLIP CLAIMANT EMPLOYER CARLOS A com AL WELLS Identification Number:-- Employer Account: wage Claim Number: 13 05011.8--0 Federal Entity ID: If you wish to protest this wage claim. you must mail your reply to the address shown at the top of the enclosed Employer Response Form. However, if you agree that the claimed wages are due and want to submit payment, please send your cashier's check or U.S. Postal Money Order to: Texas WorKforce Comission Labor Law Payment Division P.U. Box 684483 Austin, TX 73768-4483 IMPORTANT To insure proper handling enclose this sheet: with your payment, put the Claimant's Name and social Security number on the face of the check and complete the information below. List deductions from the gross amount, it any. Business Name Owner Name Address Line 1 Address Line 2 City, St, Zip TWC TAX Account Number Federal TAX ID Number Please provide the Labor Law Department written notification of any change in your address. Farm LL-25Z ("597) STATE or TEXAS - TEXAS WORKFORCE COMMISSION Labor Law 8 101 East 15th street Date: 09" "3 Austin, Texas 78778--0001 WAGE CLAIM '3 05mm" ACKNOWLEDGMENT NOTICE EUR YOUR INFORMATION: Your wage claim has ooen received by the Labor Law Department, We have notitied the employer and have requested ii response. Please be ewere that If any wages are determined due to you, they must first be collected from the employer before we can send them to you. Wage amounts awarded In wage claim cases are not drawn from state funds. Due to the liigli volume of claims. we cannot provide a specilic date when each step of ltie claim process will occur. You should be aware that the investigation process can take as long es six to nine months depending on claim volume. Generally, the tullowing steps will be taken: - Your wage claim will be assigned to 3 Labor Law investigator for investigation. You may be contacted by tile investigator if additional information is needed, - Based on the investigation our department will issue a Preliminary Wage Determination Eider lenu). You and the employer will have appeal rights to the PWDD. It you choose to appeal the PWDO. you must send a written appeal within 21 days, it neither you nor the employer requests an appeal or iudicial review, and it the amount ordered due is not submitted try the employer within an days after the date of the Pit/on, our Collections Unit will pursue collection ol the amount irom the employer. - If the money cannot be collected. tlien ii lien may he filed as a permanent record ol the debt owed to you by tne employer. Any money collected on your henall will be forwarded to you provided we have your current mailing address. We hope this iniormotion on our procedures will be helpful to you and reduce any uncertainties you may have pending a decision on your case. Please keep Information for your future reference. Any inquiries or luture correspondence should include your claim number as listed at the top oi this page. ATTENTION It is your responsibility to notify us in writing if your address or phnne number changes. it you cannot be contacted the likelihood of your collecting wages will be reduced Form LL-11 . . a; maisfflistflua Frans Wage claim -- TEXAS WORKFORCE COMMISSION, LABOR LAW SECTION 101 EAST 15TH TEXAS 15779-0001 woman-5243 or 95124754074! ur'ruD {Hailing Impuired); Fax (612-475-8025 To TITLE 2 BI. TEXAS MBOR CODE) FLEASEWNITE CLEARLV IN INK Mme: seem Secumy Number Is agIIvnnI. hm mm Ia lncIufln il wiII deIay processing Your cIaIm CLAIMANT INFO TIONI INFORMATION ABOUT YOUR YauereM. BuslnassNamu JIM SWIM Mid-l Anaflmen any sm Sammy Number_ any saw 15,. ZIF Hume Fhme Phon amnuaua .-- Work varumvuumrnuna II . PLEASE FOLLOWING EMPLOYMENT INFORMATION: What work you Peflarm? [It 2. aegIm-Ing data oIempInymenIiZ/ I) EmploymeI-II Hmlus wIth (his ampIaysr: amplaysd [gialn dale Reason Ier separatlan: - II a . 3' When wars ynur reguIany scheduled payaaya? mm was your rate a! nay? (aamyles: saw>>. 51 tin/puns, Sl/sq. Whawm me agreed work schedule? Hdeuy. Mom/m. m4 4. Wa: your nampnnaauon agraamem [3 oval (plaaso much a copy] SI Were "In claimed wages earned In Texas? Mes No 1' ml, was Iha lob convuelad In Texas? [1 ND 6. Wsmaxas dedunm from your paycheck? 0 Yes arm: 7' Ihe employer sun In huslneu? B433 8. lama employer!" bankruptcy? Yes No flew 41w 9' Whal Is Ihe mm: and phone bar n! ur a In, 11. "you am rolzlad II: the amploynr, 5cm 12' Chaos: tyne(s) uf unpald wagas -elow that has! describe your claim and wma me amounleI unpalfl ma", Name the grais amnunl of wagcs due. NnIa: Yam camel me for raceway DI any We VI expenses. sum expenses are nulmgw ananannoflu mm. ovmlmo UnplId lama Fwy Enluw MlnImum TOTAL UNPAIDWAGES CLAIMED mk {Le fa! bu uulw (Ad WIVED The M095 Ihfll h! pay. Iva/[daypax severance arpamn! 771999 GBIIHGI D0 I WIIHHII yI/Ilvy AUG 2 9 2013 (ConIInuofl on mick) . LABOR IAW6 y ' ^r Pffi , ':.. ..t.. ^.^. ^. w,t. ^., , , . ^. 1. V^..1" s..,W,.^,w+144•1 etyW.J 1•a..i r.i 2 o i,. ^ 13, What was the scheduled payday(s) for these clalmed wages? Oate(s) o2 14. If olalming regular, overtirrtel ertdlor minimum wage, what were the dates you worlced for which you received no wages7 2,.^ From Plaqgst ovlslulrr {um ynu dafgrmfi7rirl 124434 *001 K1101d111 VI11nrl•+IK3Mt al T'r q" Thlttl tL 91f1Y1 t.-lI I"blJMi?, ISV (JOL J.II^VLV i^t'^IIUt L ndn tTMa'F 1 MAY RF ASSESSED AN ADMINISTRATIVE 1 Your VVage CGIaIITI mll$t t7e SlaneU k+rylvw allsl nnubl Uo ovw+nl to bmfcrra a 7'wxoo Workfaroo Q5xtrn^nprv4or%tat3ua or a hlatary thlblln 5 Watmartrs Signature Date Before me the urldcrslgnod authority, on this day pereonally appeared the aba+fe named clalmant, who on aath ttatos to have knowledge of the racte sot forth In this we 41aim, and that the rtatter and facts set rorih therein are to the besl of the 61aimant's knotv[adge true and ao3ra0l. e4q Texas Workforce Commisdion Office No. P '^L^K _ or Notary Pttttllc My Commission Expires GpfnplnlbdlOrnta ^ftQUldo& W com^Cqon3 to fholndlvJduatlnfqrrlratJom =larnDdiA this lalm shai+ko aanJ to the 7SNG Labvr4ow SoC5Pn, YQ1 E 75th St„ Rm, t247, AusI11L YX arWrflfnq fo TWC ?0778-0001. (514475,2079. JnplylduaJa mby IqeoJva and rovlawlnfol^trM{!an 1^nt 7LVC bolleda ahnul lhelnAyldtra! CyOR^A+GnG1p^^yyt^slS11^f1Y560^OfPr^•^g Opan Racorrts, 1019 151h St, Rm. 260, A1tsNn, 7X 78778•09A'!• QUG 2 9 2013 LAB ®R.LAW Nu $115131 I-rnm: my: 4 . .. 08/1 3/13 Name: Address: 11.: nuns: .u uniuul My "rm: misiml dwuumn a: by our inu'tuflon calm/am mm: :11 mwmulhm mum gum-a um :Im'xuw' mm Ina-10521:: again/am: mam RECFJVED AUG 2 3 2013 LABOR LAW 6