Form Lb001ff - Fast Food Worker Complaint Form Page 2
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1
2ADDITIONAL INFORMATION
Please provide here any additional details regarding the previous questions.
Also, please add any additional information about possible labor law violations at your job.
READ THE FOLLOWING BEFORE SIGNING BELOW:
PLEASE ATTACH TO THIS FORM PHOTOCOPIES of any papers that are related to your work, such as W-2
forms, 1099 forms, paystubs, checks, etc. DO NOT SEND ORIGINALS.
In filing this complaint, I understand that the Attorney General is not my private attorney, but represents the
public in enforcing laws designed to protect employees. I also understand that if I have any questions regarding
my rights and responsibilities I should contact a private attorney. I understand that the Labor Bureau will keep my
personal information confidential unless and until it files a lawsuit against the employer, and will attempt to
contact me before filing a lawsuit. I will contact the Labor Bureau if my telephone number or address changes.
The above complaint is true and accurate to the best of my knowledge.
I swear under penalty of perjury that the above information is true and accurate.
Signature:_____________________________________________
Date:_____________________________
Return to:
New York State Office of the Attorney General, Labor Bureau
120 Broadway, 26th Floor
New York, NY 10271
Fax (212) 416-8694
labor.bureau@ag.ny.gov
Your complaint will be read by an attorney who will contact you by telephone or mail. If we need to speak with you
after reading your complaint, we will contact you to schedule an appointment.
LB001FF - 05/13
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