Minimum Wage Complaints

Employee First Name (required)

Employee Last Name (required)

Date of Birth (required)

Example: mm/dd/yyyy

Social Security Number (Last 4 digits only, optional)

Employee Address

Employee Street Address (required)

City (required)

State (required)

Zip (required)

Employee Phone Number (required)

Employee Email Address

Start Date of Employment (required)

Example: mm/dd/yyyy

End Date of Employment

Example: mm/dd/yyyy

Present Employer (required)
Yes
No

Language

Do You Speak English? (required)
Yes
No

What Language Would You Prefer We Contact You In? (required)

Are You a Veteran of U.S. Military Service OR Active Duty U.S. Military?
Yes
No

Company Name (required)

Company Address

Company Street Address (required)

City (required)

State (required)

Zip (required)

Company Phone

Company Phone Number (required)

Extension

Owner's Name (required)

Owner's Phone Number

Total Number of Employees in Company

Project Name

General Contractor

Project Address

Project Street Address

City

State

Zip

If Work Includes Multiple Sites, Please Elaborate Here
500 Character Maximum

Your Project's Supervisor/Foreman's Name, Title

How Long Have You Been Employed On This Project?

From

Example: mm/dd/yyyy

To

Example: mm/dd/yyyy

Present Employer
Yes
No

Describe the Kind of Work You Performed

What Was Your Rate Of Pay For Work Performed?

Hourly Rate

Salary Per Week

Other

How Were You Paid? (required)
Company Check
Personal Check
Cash

By Whom Were You Paid? (required)

Have You Been Paid At Least 1 and 1/2 Time For All Hours Worked Over 40 in One Week? (required)
Yes
No

Did You Receive a Pay Stub? (required)
Yes
No

Please Check Off Any Taxes, Benefits For Other Items Taken by the Employer From Your Hourly Rate of Pay
State Taxes
Federal Taxes
Health Insurance
Pension/Annuity
None
Other (specify below)

Tips, If Applicable (Specify Amount)

Other Documents Taken

Did You Make a Personal Demand For Your Wages Owed? (required)
Yes
No

If Yes, What Was the Employer's Response?
Maximum 300 Characters

Have You Been Retaliated Against For Inquiring About Your Wages? (required)
Yes
No

If Yes, Please Explain
Maximum 300 Characters

Have You Been Asked, Threatened, Intimidated, or Required to Give Back Any Part Of Your Pay? (required)
Yes
No

If Yes, Please Explain
Maximum 300 Characters

Please Provide the Names and Contact Phone Number of Co-Workers With Whom You Worked Who May Be Able to Verify Your Work
Maximum 500 Characters

Please Explain the Basis For Filing This Complaint, Including a Summary of the Total Wages That You Believed You Are Owed and Why (required)
Maximum 3000 Characters

I hereby swear that I have personally reviewed the complaint, that I have personal knowledge of the facts alleged herein and that I believe them to be true and accurate:

Signed By
Please type your full name to sign