The Legal Arizona Workers Act Complaint Form (Page 2 of 4) in pdf

Page ___ of ___

Unauthorized Alien Worker (#___)

After December 31, 2007, the following person was hired as an employee or independent

contractor by the employer named on the first page and at the time of hiring, the

following person was not authorized to work in the United States:

Name: ________________________________________

Date hired: __________________

Aliases: _____________________________________________________________________

Physical description, identifying marks: ____________________________________________

Home address: _______________________________________________________________

Phone number: _______________________________________________________________

Date of birth: __________________ Social Security number: _________________________

Job description: _______________________________________________________________

Address where this person works or worked for employer: ______________________________

What information leads you to believe that this worker was not authorized to work in the United

States?______________________________________________________________________

____________________________________________________________________________

Did the employer know that this worker was not authorized to work in the United States? ________

If your answer is “yes,” what information leads you to believe that the employer did know that

this worker was not authorized to work in the United States? ____________________________

____________________________________________________________________________

Did the employer check this worker using the E-Verify system? _________________________

If so, when? __________ What was the result? ______________________________________

Did the employer check this worker using the Social Security Number Verification Service? ____

If so, when? __________ What was the result? ______________________________________

Did the employer complete an I-9 form for this worker? _____ If so, when? ________________

Did the employer accept any false documents from this worker in the I-9 process? __________

If your answer is “yes,” did the employer know the documents were false? _________________

What documents were false? ____________________________________________________

What information leads you to believe that the employer knew that the documents were false?

____________________________________________________________________________

Use as many copies of this page as necessary to describe every unauthorized alien worker, one

worker per page, then number each page at the top right corner, beginning with page “2.”

Rev 6/08 p2

The Legal Arizona Workers Act Complaint Form Page 2