Dlse form 55 2026

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Click ‘Get Form’ to open the DLSE Form 55 in the editor.
Begin by entering the EMPLOYER NAME. This should be the name of the business or the owner's name if no business name exists.
Next, fill in your EMPLOYEE NAME, which is required for claiming unpaid wages or meal/rest period violations.
Input the CASE NO. once assigned after your claim is reviewed and approved.
Specify the PAY PERIOD DATES, indicating the time frame for which you are claiming unpaid wages.
Enter your HOURLY RATE based on your pay structure. If salaried, calculate it accordingly as described in the form.
Fill in the number of REGULAR HOURS worked and OVERTIME HOURS, ensuring accurate calculations based on your records.
Complete sections for DOUBLE TIME HOURS and any missed MEAL & REST PERIODS, detailing how many were not provided during your pay period.
Finally, total each column to summarize hours worked and amounts owed, ensuring all calculations reflect what you should have been paid.

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