Form Llc-15 - Prevailing Wage Complaint - Pennsylvania
ADVERTISEMENT
1
2prevailing wage complaint
This form is used for filing complaints under the Pennsylvania Prevailing Wage Act of 1961. Persons returning
this form should complete all parts, including the reverse side.
retUrn to:
Bureau of Labor Law Compliance
1301 Labor & Industry Building
Seventh & Forster Streets
Harrisburg, PA 17121
Telephone: 717-705-5969 or
1-800-932-0665
FAX: 717-787-0517
pleaSe print:
Name of Person Filing Complaint _____________________________________________________________________
Address _________________________________________________________________________________________
street
CItY
state
zIp Code
Date of Birth____________________________________________
telephone Number where you can be reached between 8:30 a.m. and 5:00 p.m. (______) ______ — _______________
(INClude area Code)
after 5:00 p.m. (______) ______ — _________________
Type of Work Performed ____________________________________________________________________________
Location of Employment_____________________________________________________________________________
street
CItY
CouNtY
state
zIp Code
Project Name and County Location _________________________________________________________________________
Name of employer (against whom the Wage Claim is filed) __________________________________________________
Company Name, if any __________________________________________ Telephone (______) ______— _______________
Address _________________________________________________________________________________________
street
CItY
CouNtY
state
zIp Code
date Hired _________________________________ are you still employed by the named employer?
Yes
No
If No, give the last date worked ___________________________ Was your termination:
Voluntary
Involuntary
1. Was there a written contract of employment between you and the named employer?
Yes
No
If Yes, please attach copy.
2. Were you notified by the named employer as to when and where you would be paid?
Yes
No
3. What was your regular payday to be? (check one)
Weekly
Bi-Weekly
Monthly
other ____________
4. Were wages paid to you in a form other than a check?
Yes
No
other (cash) _______________________
5. What was the latest rate of pay agreed upon between you and the named employer?
Hourly $_________ Weekly $_________ other, please explain _______________________________________________
What are the total wages claimed by you? $ ____________________________________________________________
complete reverSe Side
llC-15 REV 11-07 (Page 1)
CommoNwEalTh of PENNsylVaNia
DEPaRTmENT of laBoR & iNDusTRy
BuREau of laBoR law ComPliaNCE
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business