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

DEPARTMENT OF HOMELAND SECURITY

OMB Control No. 1600-0002
Expiration Date 01/31/2015

EMPLOYEE CLAIM FOR WAGE RESTITUTION

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, Acquisitions 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
01/31/2015.
Contract Number:

TO:

The Government Accountability Office
Claims Division
Washington, DC 20548

Date of Claim:
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 as
during the period from
(Job Title)

to
(mm-dd-yyyy)

(mm-dd-yyyy)

.

This claim constitutes the total amount claimed due and unpaid for the period of employment indicated.
Employee's Address:

Employee's Signature:

DHS Form 700-4 (12/07)

Authorized for Local Reproduction