West Virginia Wage Bond Employee Release Affidavit Form - Free Download
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EmployeeSwornStatement
I,____________________________,herebycertifythatIamanexistingor
previousemployeeof andIunderstand
thatthisstatementwillbeusedbytheDivisionofLabortodeterminewhetheror
notthatcompany’swagebond,whichwaspostedtoprotectemployeewages
andbenefits,maybeeligibleforrelease.
Placea Pmarkincorrectbox
Yes No
Placea Pmarkincorrectbox
Yes No
Iamanexistingemployee Ihavebeenpaidallwagesandbenefits
Iamapreviousemployee
IhaveNOTbeenpaidallwagesand
benefits *
EmployeeContactInformation:
Mailingaddress:
DaytimePhone#orothercontactinformation
*Ifyouareowedwages,youmustfileacomplaintwiththe DivisionofLaborassoonaspossible.TheDi visionwillnot
releasethecompany’swagebond until anyandallexisti ngwagecomplaintsarei nvestigated.Ifneeded,wagecomplaint
forms(RFAs)areavailable onourwebsite.
EmployeeSignature
NotaryPublic
Taken,sworntoandsubscribedbeforemeonthisthe_______dayof
,20 .
NotaryPublicSignature
Mycommissionexpires:__ ______________
Formdate4/ 15/09
Phone(304)5587890
Fax(3045583797
http://www.wvlabor.org
WestVirginiaDivisionofLabor
Building6,Room749B
Charleston,WestVirginia25305