Prevailing Wage Complaint
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4BEFORE FILING A WAGE CLAIM,
PLEASE READ THESE INSTRUCTIONS CAREFULLY!
Do Not Fill Out The Prevailing Wage Complaint Form If:
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You acted as an "independent contractor" and not as an "employee" of the business.
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You are self-employed or an owner/operator.
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You have filed suit against your employer for the same wage or fringe benefit claim.
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You already have a civil court judgment involving this claim.
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You are trying to obtain a W-2 or 1099. If so , you should contact the Internal Revenue
Service at 1-800-829-1040.
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Your employer has filed bankruptcy or has been determined bankrupt. If so, you will need to
contact the Bankruptcy Court for further instructions.
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You do not know your employer’s address or location.
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You intend to file against more than one business. Use a separate wage claim form for
each business against whom you wish to file a claim. Also, each claimant intending to file
against an employer must use a separate claim form.
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The statute of limitation s for your claim has expired. A 3-year statute of limitations applies
when filing a complaint for prevailing wages.
FILING A WAGE CLAIM
IF CLAIM FORM IS NOT COMPLE TED AS INDICATED IN THESE I NSTRUCTIONS IT MAY
BE RETURNED TO YOU.
Read all questions on the claim form carefully before answering.
Fill out the claim form
completely, legibly and accurately, providing as much of the requested information as possible.
In order for your claim to be processed the following information must be provided:
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Name and address of the complainant.
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Provide a telephone nu mber where you may be reached during the day. If your address
or telephone number changes, it is your responsibility to notify the Department
immediately or your claim may be closed.
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Name and address of contractor alleged to have committed the violation. Your claim will be
returned if a complete address is not provided.
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Contracting agent name and address, project name and description, location where the
work was performed; and construction dates.
WHD-943B
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