Notice of Payday Law Wage Claim Appeal

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USE THIS FORM ONLY TO SUBMIT A PAYDAY LAW WAGE CLAIM APPEAL

To contact TWC for any other reason, see: Contact Information

If you have moved since TWC mailed the document you are appealing, mail or fax your change of address to:
TWC Special Hearings Section, 101 East 15th Street, Austin, TX. 78778-0001 or (512) 463-9318.

See the document(s) you received from TWC or Texas Payday Law Appeals for more information about the Payday Law wage claim appeals process.

indicates required information

Claimant's Information

Last Four Digits of Claimant's Social Security Number:

Claimant's Name:

First Name:

Middle Initial:

Last Name:

Appeal Details

Employer/Business Name:

Wage Claim Number:

(Without dashes.)

What is your connection to the claimant?

Note: If you are not the claimant, provide your name.

Name of Person Submitting the Appeal:

First Name:

Middle Initial:

Last Name:

Phone Number Where You Can Be Reached:

() - Ext:

(Include area code and extension.)

Decision You Are Appealing:

Caution: If you submit an appeal before TWC mailed the determination or decision, it will not be accepted.

Date of Letter You Are Appealing:

Year:

Was a hearing scheduled with the Appeal Tribunal or Commission Appeals?

Yes No

If Yes (Required):

What is the Appeal Number?

Did you participate in the hearing?

Yes No

Describe your reason for appealing. If you are submitting the appeal late or you did not attend a hearing, include an explanation about why your appeal is late or you did not attend. Also include any dates or times when you cannot participate in a hearing.

Reason for Appeal and Accommodations Needed:

If you need an interpreter during the hearing, what language do you need?

Caution: Your appeal IS NOT COMPLETE until you submit it and receive a confirmation number.