CHECKLATE - WAITING-TIME PENALTY CLAIM WORKSHEET
California | Prepared October 27, 2026
https://checklate.money/claim-waiting-time-penalty-california

This is a private organizing aid, not an official claim form or a filing.
Edit this file on your device or print it. It sends nothing to CheckLate.

EMPLOYER AND WORK
Employer legal name and address:
Where I worked:
Job / industry:
Date hired:

JOB ENDING
I quit / was discharged / other:
Last day:
If I quit: notice date and planned last day:
Record supporting these dates:

PAY AND PAYMENT
Hourly rate or salary:
Usual hours per day and workdays per week:
Overtime, commissions or varying pay/schedule:
Final wages paid in full? If not, what remains unpaid?
Amount received and date:
Any earlier pickup offer, mailing request or mailing date:
Records: pay stubs, bank record, envelope, messages:

POSSIBLE PENALTY - KEEP SEPARATE FROM ALREADY-PAID WAGES
General final-pay deadline and reason:
Daily wage calculation:
Qualifying days claimed (maximum 30):
Possible penalty (daily wage x qualifying days):
What happened / why I believe payment was willfully late:
Any employer explanation, disputed wages or earlier payment offer:
Any settlement, release, claim or lawsuit already started:
Uncertain facts / questions for review:

FILING CHECKLIST
[ ] Read current instructions: https://www.dir.ca.gov/dlse/HowToFileWageClaim.htm
[ ] Check the current form, required sections and signature.
[ ] Paper Form 1 rev 07/2025: Part 4 final-payment facts; item 37 waiting-time penalties.
[ ] Distinguish wages already paid from unpaid wages and penalties.
[ ] Include available copies; keep originals and a copy of the submission.
[ ] Keep filing confirmation and follow later notices.

The penalty requires willful nonpayment; good-faith disputes, earlier valid
payment offers, agreements and other facts may change the result. Estimates
are not eligibility decisions. This worksheet and a CheckLate inquiry do not
file a claim or pause a deadline. Ask for advice if the deadline or route is unclear.