Form LS223: How to Complete the New York Labor Standards Complaint Form

Form LS223 is the paper form behind a New York wage claim. It runs six pages and ten parts, and the Department of Labor prints one instruction on page one: read Information About Filing a Claim (LS223.2) before filling it out, and answer every question for each part related to the claim. Complete information is what lets the Department review the complaint and accept it for investigation. If the Department does not have enough information to proceed, or the claim appears invalid, it will contact the person who filed.

The form in one table

Check first: LS223 is not for every claim

The form lists claims it cannot accept. Do not start with LS223 if the claim is for work performed outside New York State, from a person employed in an administrative, executive, or professional capacity who earns over $1,300 gross per week, from a person employed by a public entity such as a town, county, or city, from a person in business for themselves, or for work performed on a public work project. Public work claims use form PW-4. Farm workers use a different form, LS710, instead of LS223. The $1,300 figure is printed on the form with citations to Labor Law sections 190(7) and 198-c(3). Anyone working in New York State may make a complaint to the Department, according to the note printed on the form.

Gather these records before you write

Most of the form is transcription from records the filer already has. Pull them together first, because several parts ask for exact figures and dates.

• Pay stubs and copies of checks or check stubs, including any check the bank did not honor, with its check number and the payroll week ending date.
• The employer's business name and legal name if different, its mailing address, phone, and email, the owner names and titles, and the employer's bank name and location.
• The job record: job title, type of work, date hired, who hired you, manager or supervisor names, who paid the wages, and the worksite address.
• The pay record: rate of pay and the period it covers, overtime rate, tips if earned regularly, payday and the period it covered, how often wages were paid, and how wages were paid.
• The work-week record: start and end times for each day, time off for meals, and total hours, for the weeks claimed.
• For a wage supplement claim, the written policy or handbook that promised the benefit, or notes of the verbal promise, with the benefit type, the period earned, and the payment due date.

Parts 1 to 3: the filer, the business, and the job

Part 1 asks for the person filing the claim: full name, another name known by at work, mailing address, phone numbers, email, and primary or preferred language. Part 2 asks for the business the claim is filed against: business name, legal name if different, legal entity type, mailing address, phone, and email, then owner names and titles with a separate mailing address, phone, and email. It also asks for business type, hours of operation, total number of employees, whether the company is still in business and, if not, when it closed, the employer's bank name and location with a copy of a check or check stub attached, and whether the employer has filed for bankruptcy, with Unknown as an answer.

Part 3 asks for employment information: job title, type of work performed, date hired, name and title of the person who hired you, names of the manager, supervisor, or foreman, and name of the person who paid the wages. It asks for the worksite address, whether the filer regularly traveled outside New York State for work, and the relationship with the business: still employed, discharged, quit, or temporarily laid off, with last day worked and reason for leaving. It asks about union membership, rate of pay per day, week, hour, or other period, overtime rate of pay, tips earned on a regular basis and the average amount per hour, whether the employer kept tips and how much, payday and the period it covered, how often wages were paid, and how wages were paid: cash, check, direct deposit, pay card, or a combination explained in words. It closes with uniforms: whether a uniform was required, a description, whether uniforms were free of charge, and, if not, how uniforms were purchased and how much they cost.

Part 4: unpaid wages, one row for each week

Part 4 is for wages owed, and the form directs filers to Part 7 for overtime pay. Use one row for each week, and attach separate sheets for additional weeks or for more information. Each row records the week ending date, payroll days worked, number of hours worked in the week, rate of pay, gross wages earned or promised, illegal deductions from wages, gross wages paid, and the difference between gross wages owed and gross wages paid. Gross wages mean the amount earned before taxes or other deductions. The form works one example row: a week ending 4/4/2017, 7 days, 35 hours, $16.00 per hour, $560 gross wages, $0 paid, $560 owed. Question 33a covers a paycheck the bank did not honor: give the check number and payroll week ending date, and provide a copy of the check if available. Question 33b asks for the claim range, the dates the wage claim covers, from and to. A total line closes the part.

Part 5: unpaid paid sick leave

Part 5 is for paid sick leave owed. The form restates the rule as printed on it: Labor Law section 196-b requires employers with five or more employees or net income of more than $1 million to provide paid sick leave to employees, with accrual from September 30, 2020 at one hour for every 30 hours worked, and use of accrued leave from January 1, 2021. Each row records the time period paid sick leave accrued, the amount accrued, the dates paid sick leave was used, the amount of benefit time owed, the regular rate of pay, and the amount of benefit payment due. The worked example on the form shows 16.5 hours accrued over 9/30/20 to 1/8/21, 8 hours used on 1/11/21, $20 per hour, $160 due. A total line closes the part.

Part 6: unpaid wage supplements

Part 6 is for wage supplements owed. Wage supplements are fringe benefit payments promised by the employer, such as vacation pay, expenses, and holiday pay. Question 34 asks the filer to explain the benefits promised or attach a copy of the written policy or handbook. Each row records the type of benefit owed, the time period the benefit was earned, the date benefit payment was due, the amount of benefit time owed, the amount of benefit payment due, and whether the benefit was promised by written policy or verbal promise. The worked example shows vacation pay earned 1/1/16 to 12/31/16, payment due 1/1/17, one week, $700, promised by written policy. A total line closes the part.

Part 7: minimum wage and overtime, with a work-week schedule

Part 7 is for pay below the state minimum hourly wage, unpaid overtime, extra pay for working two shifts in one day, or extra pay for working more than 10 hours in one day. The form states that most employees must be paid at least the minimum wage and time and a half if they work more than 40 hours per week. It does not print the current minimum wage rate, so do not copy a rate from an old copy of the form. Questions 35a through 35e ask whether the filer is paid the minimum wage for each hour worked, time and a half for hours over 40, any wages for hours over 40 and how much per hour, and an extra hour for two shifts in one day or more than 10 hours in one day. If the answer to any of those is no, question 35f asks for an explanation and a schedule of the work week: for each day, time the workday started, time it ended, time off for meals, and total hours, with a weekly total. The form works an example day of 10:00 am to 11:00 pm with 30 minutes off for meals, 12.5 hours. Questions 36a through 36e ask whether the hours are the same every week, an estimate of average hours per week if not, whether call-in pay or uniform maintenance pay is owed with dates, the claim range for the minimum wage or overtime claim, and the regular and overtime rates of pay during that range, with separate date ranges where rates changed.

Part 8: non-wage complaints

Part 8 is a checklist. Check every item that applies, explain, and provide an additional sheet if needed. The items are: the employer failed to provide a 30-minute meal period, and whether the filer was paid for time worked when the meal period was not provided; provide a wage statement or pay stub; provide a day of rest; provide a notice of pay rate with all required information; provide for accrual of required New York State paid sick leave; post required notices or the minimum wage poster; follow rules for employment of minors under 18; and any other failure, described in words.

Parts 9 and 10: background, help, and signature

Part 9 asks for claim background: whether the filer asked for the wages, with an explanation of who was asked, when, and what happened, and whether the filer has already taken action such as filing in small claims court or a lawsuit to recover the wages, with an explanation if yes. Part 10 asks about claim assistance: whether the filer has a representative such as a private attorney or advocacy group, the representative name, whether the representative assisted in filing the claim, whether the representative has been paid or will be paid, and whether the Department should speak with the representative. Representatives must submit a Letter of Representation, form LS 11. It also asks whether anyone other than the representative helped fill out the form, and who helped and why. An additional comments section follows. The signature block certifies that the information is true to the best of the filer's knowledge, notes penalties for making false statements, authorizes the Commissioner of Labor, deputies, or agents to receive, endorse in the filer's name, and deposit any checks or money orders made out to the filer as payment on the claim, and states that the filer will notify the Department if contact information changes. The form closes with the instruction to return the completed form to the address on page one.

Send it, then what happens

Mail the completed form to the Division of Labor Standards at the address printed on page one, or file the claim through the Department's claim page linked from the unpaid wages pages. The Department's process page states that filers should always answer Department requests, because answering prevents delays. The Department first determines whether it is legally able to intervene. If the claim is accepted, the filer is notified by mail and assigned a case number starting with LS. An investigator contacts the employer and, in some cases, visits the place of employment. A compliance conference may be held, with the filer and the employer invited to resolve outstanding issues. The filer receives updates periodically while the case is actively investigated and is notified once the investigation is concluded. If a violation is found, the employer must resolve it, including repaying wages owed. If the employer fails to repay, the employer receives an Order to Comply from the Commissioner of Labor. The Department states it cannot guarantee it will be able to collect. A separate court track remains available; the filing guide states the six-year window and the tolling rule for that track.

What this page does not state

No fee for filing LS223 is stated on the form or on the Department process page opened for this guide, so no fee figure appears here. No current minimum wage rate is stated, because the form does not print one. The contents of the LS223.2 instructions are not restated here, because only the form itself was read in full for this guide; read the current LS223.2 before filling out the form, as the form directs. The six-year filing window, the tolling rule, and the court alternative in full are stated in the filing guide linked below, not repeated here.

For the filing route as a whole, see How to File a Wage Claim in New York. To compare filing routes in other states, see the Wage Claim Filing by State directory. To check a deadline first, use the Wage Claim Deadline Checker.

Source

Form, fields, and filing routes: New York Department of Labor, Labor Standards Complaint Form LS223 (02/25), read in full 2026-11-01; The Labor Standards Complaint Process, read 2026-11-01. The six-year window and tolling rule are stated in the filing guide, whose facts were verified 2026-10-24. Facts verified 2026-11-01.

This page explains how the process works and what the official rules say. It is general information, not legal advice. For a dispute about your specific situation, talk to a lawyer or your state labor or consumer agency.