Complaint Form

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For Office Use Only
For Office Use Only
Vermont Department of Labor
WAGE AND HOUR PROGRAM
Response:
P.O. Box 488
Montpelier, VT 05601-0488
Telephone: 802-828-0267
Fax: 802-828-4198
Labor-WageHour@state.vt.us
Email:
Date
COMPLAINT FORM
Name: ____________________________________________________ Telephone Number: ______________________
Mailing Address: ____________________________________________________________________________________
(P.O. Box / Street)
(Town)
(State)
(Zip Code)
If no telephone, how may you be reached? _______________________________________________________________
May we leave an explicit message for you, including information about this complaint? _____________________________
Do you wish us to tell the employer the source of this complaint? ______ (If no, the Wage and Hour Program will NOT
contact you with the results of our inquiry.)
Business Name: _________________________________________ Business Telephone Number: ___________________
Business Owner s Name: ______________________________ Type of Business: ________________________________
Business MAILING address: ____________________________________________________________________________
(P.O. Box / Street)
(Town)
(State)
(Zip Code)
Business PHYSICAL address: __________________________________________________________________________
(Street)
(Town)
(State)
Are you an employee of this business? ___________________________________________________________________
Complaint about (check all that apply)
Unlawful child labor. [21 V.S.A. Chapter 5 Subchapter 4/Child Labor Rules]
Failure to provide a proper wage statement with each wage payment. [Vermont Minimum Wage Rules]
Failure to provide reasonable opportunities for employees to eat and to use toilet facilities [21 V.S.A. §304]
Unauthorized payment of wages by electronic transfer [21 V.S.A. §342(d)]
Failure to post mandatory employment law posters. [21 V.S.A. §442, Vermont Minimum Wage Rules]
Other (describe):
Please explain your complaint:
I hereby certify that, to the best of my knowledge, these statements are true.
Signature: ____________________________________________________
Date: ________________________
Equal Opportunity is the Law
The State of Vermont is an Equal Opportunity/Affirmative Action Employer. Applications from women, individuals with disabilities, and
people from diverse cultural backgrounds are encouraged. Auxiliary aids and services are available upon request to individuals with
disabilities. 711 (TTY/Relay Service) or 802-828-4203 TDD (Vermont Department of Labor).
WH-2 (11/10)

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