Form DHS 700-4 DHS 700-4 Employee Claim for Wage Restitution

DEPARTMENT OF HOMELAND SECURITY

EMPLOYEE CLAIM FOR WAGE RESTITUTION

OMB Control No. 1600-0002
Expiration Date 02/28/2011

PRA Burden Statement: This collection of information is mandatory and will be used to fulfill the requirements of the
Homeland Security Acquisition Regulation (HSAR). Public reporting burden is estimated to average 1 hour per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the
Office of the Chief Procurement Officer, Acquistions Policy and Legislation, Department of Homeland Security,
Washington, DC 20528. Please note that an agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control
number for this collection is 1600-0002 and it expires 02/28/2011.
Contract Number:

TO:

The Government Accountability Office
Date of Claim:
Claims Division
Washington, DC 20548
Employee's Full Name:

I hereby make claim for payment of unpaid wages due me in the amount of $
as an employee of

( Name of Contractor and/or Subcontractor)

performing the work under the above number at
(Work Locations)
, I was employed
during the period from

as
(Job Title)

(mm-dd-yyyy)

. This claim constitutes the total amount claimed due and unpaid

to
(mm-dd-yyyy)
for the period of employment indicated.
Employee's Address:

Employee's Signature:
DHS Form 700-4 (12/07)

Authorized for Local Reproduction