Form Erd-9850 - Wisconsin Prevailing Wage Rate Complaint - State Of Wisconsin Department Of Workforce Development

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State of Wisconsin
Wisconsin Prevailing Wage Rate Complaint
Department of Workforce Development
Equal Rights Division
Personal information you provide may be used for secondary purposes. (See Section 15.04(1)(m), Wisconsin Statutes for details.)
This form must be used to file any complaint regarding an alleged violation of Sections 66.0903 or 103.49,
Wisconsin Statutes, or Chapter DWD 290 of the Wisconsin Administrative Code.
The filing of this form does not require this department to conduct an investigation to determine the validity of
your complaint. It is the complainant’s responsibility to provide proof of the validity of his/her complaint.
Any form that is not properly completed will be returned to the complainant. Enclose a separate sheet of paper
if you need additional space.
Return ALL completed forms and evidence to:
Equal Rights Division, Labor Standards Bureau, P O Box 8928 Madison WI 53708.
Please type or print all information.
[1] Complainant Information:
Name
Social Security or Fein Number (optional)
Mailing Address
City, State, Zip Code
Home Telephone
Work Telephone
[2] Employer Information:
Business Name
Owner Name
Mailing Address
Telephone Number
City, State, Zip Code
County
[3] Detailed Complainant Information:
I am a o Current Employee
o Former Employee o State or Municipal Official o Other
o Union representative (If you are a union representative, do you presently represent any of the employees that
o Yes o No
work for the employer indicated above?)
o Yes o No
Has the employer filed bankruptcy?
o Yes o No
Is the employer still in business?
o Yes o No
Have you retained an attorney to resolve this matter?
If the complainant indicated in (1) above has never been employed by the employer indicated in (2), the
complainant must provide the name, address and telephone number of an allegedly aggrieved employee and
must complete the remainder of this form to the best of his/her ability before this complaint will be investigated.
Under these circumstances a complaint will only be investigated for the allegedly aggrieved employee indicated
below. A separate form must be completed for each allegedly aggrieved employee.
Name
Social Security Number
Mailing Address
City, State, Zip Code
Home Telephone
Work Telephone
[4] Alleged Violations: Check the appropriate boxes and briefly explain the nature of the wage and hour
violation(s) allegedly committed by the employer. Only those violations checked will be investigated:
o Straight Time
o Travel Time
o Improper Classification
o Weekly Overtime
o Banked Hours
o Kickback
o Saturday/Sunday/Holiday Overtime
o Fringe Benefits
o Retaliation
o Improper Ratio o Wages Owed Over 30 Days
o Apprenticeship
o Payroll Record o Daily Overtime o Did Not Receive Last Paycheck
o Illegal/Non-listed Deductions
You must complete page 2 of this form.
ERD-9850 (R. 12/2000)

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