Request for Payment Form

Dear :

I believe that I am entitled to the following unpaid amounts under the Employment Standards Act, 2000 (ESA). Please see attached worksheets for details and calculation:

Unpaid Wages:	$
Vacation Pay:	$
Unauthorized Deductions:	$
Overtime Pay:	$
Public Holiday Pay:	$
Minimum Wage:	$
Termination Pay:	$
Severance Pay:	$
TOTAL (Gross):	$

Please send me the total amount shown, less statutory deductions and any deductions required by court order. If you disagree with my calculation, please contact me at the telephone number given above between the hours of and .

If we cannot resolve this matter within 15 calendar days, I may file a claim with the Ministry of Labour.

For more information about the ESA, please contact the Ministry of Labour Employment Standards Information line at 1 800 531-5551 or visit the Ministry of Labour website at www.labour.gov.on.ca/english/es.

Sincerely,

Signature: Date: