Minimum Wage Intake Form

The City of Petaluma has a local minimum wage that is higher than the State minimum wage. This wage applies to hours worked within the Petaluma city limits. When calculating this wage, employers can include commissions but are not allowed to include tips and/or benefits (such as room/board allowances, medical benefits, etc.).

The chart to the right lists the correct Petaluma minimum wage(s) for 2020 - 2022. If you feel you have been paid incorrectly, please complete the intake form below.

*Note: Some locations with a Petaluma address are not located within the Petaluma city limits. Before submitting the form, please confirm that the hours were worked within the Petaluma city limits.

Today's Date * Required
MM slash DD slash YYYY
Your Name * Required
First Last
Your Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your Email * Required
Your Phone * Required
Preferred Contact Method * Required
Name of Supervisor or person in charge
Job Title/Position of Supervisor (or person in charge)
Type of Business (restaurant, gym, market, etc.)
Date of Hire * Required
MM slash DD slash YYYY
Your Job Title
Type of Work You Performed
Check which box applies
- Still working for that employer
- Quit
- Discharged (Fired, furloughed, laid off, etc.)
If no longer working for that employer, date you quit or were discharged
MM slash DD slash YYYY
If no longer working for that employer, have you received your final payment of wages?
- Yes
- No
Claim Period Start Date * Required
MM slash DD slash YYYY
Claim Period End Date * Required
MM slash DD slash YYYY
Wage paid per hour
Were/are you paid by the hour (non-exempt) or on salary (exempt) * Required
Were/are you eligible for commissions as part of this wage?
Upload Paystubs for Affected Pay Periods
Max. file size: 30 MB.
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Minimum Wage Intake Form

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