Form Ls-119 - Labor Standards Complaint March 2001
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2Office Use Only
State of Wisconsin
Labor Standards Complaint
Department of Workforce Development
Equal Rights Division
Personal information you provide may be used for secondary purposes.
[Privacy Law, Section 15.04(1)(m) Wisconsin Statutes.]
Return form for work done in Kenosha, Manitowoc, Milwaukee, Ozaukee, Racine,
Sheboygan, Walworth and Washington counties to:
Equal Rights Division 819 North Sixth St Milwaukee WI 53203
Return form for work done in the rest of the state to:
Equal Rights Division P O Box 8928 Madison WI 53708
Please Type Or Print In Black Ink All Applicable Information
Complainant Information
Employer Information
Mr.
Print Your Name
Business Name
Ms.
Mrs.
Your Street Address
Business Street Address
City, State, Zip Code
City, State, Zip Code
Date of Birth (mo/day/yr)
County Name
Social Security Number
Owner/Corporation Name
Home Telephone Number (include area code)
Type of Business
(
)
Work Telephone Number (include area code)
Business Telephone Number (include area code)
(
)
(
)
Check the appropriate boxes below and summarize your complaint. If you need more space, use an additional
sheet of paper and attach to this form. How much money do you think your employer owes you? Explain how
you determined the amount due. Include the time period it is for. Be as specific as possible. If your claim is
for vacation or other types of leave, please enclose copies of any written policies you have.
Overtime
Child Labor
Unpaid hours of Work
One Day of Rest in Seven
Medical Exam
Minimum Wage
Streets Trade
Deductions from Wages
Personnel Records
Seats for Workers
Severance Pay
Commissions
Bonus Pay
Vacation/Holiday/Sick Pay
Other
Remember that the department does not assume your complaint is valid just because you have filed this form.
In case of a dispute, it is your responsibility to prove that your complaint is valid.
You Must Also Complete Page 2 of This Form
LS-119 (R. 03/2001)
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