Confidential Intake Questionnaire (Wage & Hour)

If you would like HLG to review your situation, please complete and submit this form.

All information provided is strictly confidential and will not be shared with any third parties.

 

GENERAL INFORMATION

MINIMUM WAGE & OVERTIME

MEAL AND REST BREAKS

OTHER WAGES

Were you given a pay stub each period indicating wages earned, your pay rate, all deductions taken, etc...? Yes No I Don't Know

Did you receive your final paycheck on your last day of work (if fired) or within 72 hours (if quit)?  Yes No

EMPLOYMENT RELATIONSHIP

Please choose the following statements that best describe your job during the period you were not paid overtime:

MISCELLANEOUS INFORMATION

PLEASE READ CAREFULLY BEFORE SUBMITTING

Although the information you provide to us on this form is confidential, completion and/or submission of this form to us
does not create an attorney-client relationship between Hekmat Law Group (the "Firm") and you. No attorney-client relationship
shall exist until you and the Firm make a mutual decision to work together and make a written agreement stating the specific
terms of that attorney-client relationship. While this questionnaire does not create an attorney client relationship, your information
will be confidential and privileged. We will not disclose your information and you may not be compelled to disclose your
communications with us to anyone.

Please note, if you have time deadlines (or statutes of limitations) that are quickly approaching, we cannot guarantee that we will
respond in time for us to assist you in filing a lawsuit or administrative agency complaint. You should take immediate action to avoid
missing any such deadlines. Generally, the time to file employment related claims in court is one year from the date of harm,
such as termination, demotion or transfer.

By submitting your matter below, you acknowledge that you have read and understood the foregoing.