Pay Equity Complaint Form - Ri Department Of Labor And Training Page 2
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1
2The company’s reason for disparity in wages:___________________________________
Rate of Pay:$________
per hour
per week
Unpaid wages owed?
Yes
No
What dates did you work for the money which you claim you are owed?
From ____________ to ____________ Total amount owed: $_________________
(mm/dd/yy)
(mm/dd/yy)
Have you taken any other action against your employer in this matter?
Yes
No
If yes, please explain:
Will you fully cooperate with the Attorney General’s Office, including appearing in court?
Yes
No
EXPLAIN IN DETAIL the facts relating to why you are filing this pay equity complaint.
What led you to discover the disparity in wages? Please provide any details on your
complaint.
I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THIS IS A TRUE
STATEMENT OF THE FACTS RELATING TO MY COMPLAINT.
Signature:___________________________________________ Date: _____________
Print Name:_____________________________________________________________
(Minor child requires parent’s signature) ______________________________________
.
PLEASE PRINT CLAIM FORM, SIGN AND FORWARD TO THE ADDRESS AT TOP OF FORM
DLT is an equal opportunity employer/program - auxiliary aids and services available upon request. TTY via RI Relay: 711
1/2015
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