Form Ls-119 - Labor Standards Complaint March 2001 Page 2

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Employment and Wage Information
You must ask for your wages before filing this complaint.
What date did you ask? _________________
What did the employer say?
Hourly Rate of Pay
Salary
Commission
Piece Rate/Flat rate
How often were you paid?
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Other (Specify):
Did you receive tips?
Average amount of tips per day?
Yes
No If yes, were tips reported to employer?
Yes
No
$
Did you receive meals, lodging or anything else in addition to your wages?
Yes
No
If yes, please explain:
Do you owe the employer for such things as advances, merchandise or other?
Yes
No
If yes, please explain:
How many hours per day did you
How many hours per
Does the Employer keep time
usually work?
week?
records?
Yes
No
Check all the boxes next to the kinds of records that you have kept
Hours worked (If checked submit with complaint.)
Check stubs
Deduction Slips
No records
Give your jobs title and briefly describe the kind of work you did
Street address where you worked
City
State
Zip Code
County where you worked
You must complete this line. If unsure, please estimate month & year.
First date worked
Last date worked
Reason for leaving
Quit
Discharge
Laid Off
Other
Has employer filed for
Have you filed this claim in court or hired an
Is there a union to represent
bankruptcy?
attorney to collect your wages?
you?
Yes
No
Yes
No
Yes
No
Your Signature is required
Date Signed
The statements made on this complaint are true to the best of my knowledge. I understand that if the
employer wants to review this complaint, it is an open record, and will be provided to the employer under the
provisions of Wisconsin’s Open Records Law. Wisconsin law prohibits retaliatory action by an employer for
most complaints filed with the Department.
Child Labor - Complete if you were under age 18 at time of employment
Was a work permit issued?
Yes
No
If yes, provide date permit was issued:
Are you still in high school?
Yes
No
Are you enrolled in any of the following
If no, did you graduate?
Yes
No
Alternative School
GED/HSED Program
Date you graduated
Home Schooling
Charter School
Name of current or last school attended
Address of current or last school attended
Page 2

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