Download West Virginia Wage Bond Employee Release Affidavit Form for Free

West Virginia Wage Bond Employee Release Affidavit Form - Free Download

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EmployeeSwornStatement

I,____________________________,herebycertifythatIamanexistingor

previousemployeeof andIunderstand

thatthisstatementwillbeusedbytheDivisionofLabortodeterminewhetheror

notthatcompany’swagebond,whichwaspostedtoprotectemployeewages

andbenefits,maybeeligibleforrelease.

Placea Pmarkincorrectbox

Yes No

Placea Pmarkincorrectbox

Yes No

Iamanexistingemployee Ihavebeenpaidallwagesandbenefits

Iamapreviousemployee

IhaveNOTbeenpaidallwagesand

benefits *

EmployeeContactInformation:

Mailingaddress:

DaytimePhone#orothercontactinformation

*Ifyouareowedwages,youmustfileacomplaintwiththe DivisionofLaborassoonaspossible.TheDi visionwillnot

releasethecompany’swagebond until anyandallexisti ngwagecomplaintsarei nvestigated.Ifneeded,wagecomplaint

forms(RFAs)areavailable onourwebsite.

EmployeeSignature

NotaryPublic

Taken,sworntoandsubscribedbeforemeonthisthe_______dayof

,20 .

NotaryPublicSignature

Mycommissionexpires:__ ______________

Formdate4/ 15/09



Phone(304)5587890

Fax(3045583797

http://www.wvlabor.org

WestVirginiaDivisionofLabor

Building6,Room749B

Charleston,WestVirginia25305

West Virginia Wage Bond Employee Release Affidavit Form

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