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[5] Allegedly Aggrieved Employee Data:

Date Employment Began with Employer

Date Employment Ended (If a former employee)

Normal Trade/Occupation

Normal Rate of Pay

o Per Hour

o Per Week

Apprentice?

Date Indentured

oYes oNo

Does your employer normally provide you with ANY fringe benefits, such as health insurance, pension, paid

oYes o No

vacation, profit sharing, IRA, etc.?

oYes o No

If yes, did the employer pay the entire cost of such benefits?

oYes o No

If yes, indicate below the specific fringe benefits provided.

________________________________________________________________________________________

[6] Project Information: Please enter the following information for ONLY the PUBLIC WORKS project(s) on

which the employer allegedly committed the previously indicated violation(s). If project information is not

entered, no investigation will be conducted.

Name of Project

Location

Determination Number

________________________________

___________________________

_______________________

________________________________

___________________________

_______________________

Describe both the work you performed and date(s) you worked on the above named project(s)

_______________________________________________________________________________________

What trade/occupation did you perform on these public works projects? ______________________________

Do you have any prior experience in this trade/occupation while working for a different employer? oYes oNo

If yes, how many years? ___________________________________________________________________

How much were you paid per hour on the project(s) named above? $ ________________________________

oYes o No

Did you ever work any overtime?

oYes o No

Did you receive your regular fringe benefits?

oYes o No

Were any hours “banked” for use at a future date?

oYes o No If yes, send them with this form.

Did you keep any records of the hours you worked?

oYes o No If yes, send them with this form.

Did you keep your check stubs?

[7] Calculations:

oYes oNo

Do you owe your employer any money?

If yes, how much and for what? ______________________________________________________________

oYes oNo If yes, when did you ask? __________

Did you ask your employer for your back wages?

How much do you believe the employer owes you? $__________ Indicate how you arrived at this amount.

________________________________________________________________________________________

The statements and information provided above are true to the best of my knowledge. I understand that it is my

responsibility to prove the alleged violation(s) indicated and that: (1) this complaint is an open record under the

provisions of Wisconsin’s Open Records Law and a copy of it will be provided to the employer; (2) Section

111.322(2m), Wisconsin Statutes, prohibits retaliation against an employee by an employer for most labor

standards complaints filed with this department; and, (3) if the employer is found to be in compliance with all

applicable labor standards regulations, I agree to pay the DWD the actual cost of the investigation or, as a third

party complainant, a MINIMUM OF $250, or the actual cost of the investigation, whichever is greater.

Complainant Signature

Title (Optional)

Organization You Represent, if any

Date Signed

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Form Erd-9850 - Wisconsin Prevailing Wage Rate Complaint - State Of Wisconsin Department Of Workforce Development Page 2

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