Acknowledgment and Declaration

By submitting this claim you acknowledge and understand that the NYSDOL will, in the discretion of the Commissioner of Labor's authority, evaluate your claim for investigation, determine the scope of investigation on any claim accepted, and will resolve claims as expeditiously as possible. The disposition of complaints and resolution of violations shall be determined by the Commissioner of Labor. I certify the above information is true to the best of my knowledge, and I am aware there are penalties for making false statements. I authorize the Commissioner of Labor, deputies or agents to receive, endorse my name on, and deposit in the account of the Commissioner of Labor any checks or money orders made out to me as payment on this claim. I will notify the New York State Department of Labor if my contact information changes