Form Ls-119-E - Labor Standards Complaint
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1
2State of Wisconsin
Office use only
Labor Standards Complaint
Dept. 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].
The provision of your social security number is voluntary. Failure to provide your
social security number may result in an information processing delay.
Return form to:
EQUAL RIGHTS DIVISION
PO Box 8928
Madison WI 53708
Please Type Or Print In Black Ink All Applicable Information
Complainant Information
Employer Information
Advertised Business Name
Mr.
Ms.
Mrs.
First Name
Middle Name
Business Street Address
Last Name
Mailing Address, if Different
Street Address
City
State
Zip Code
City
State
Zip Code
Owner/Corporation Name
Date of Birth
Social Security Number
County Name
Type of Business
Contact Telephone Numbers (include area code)
Business Telephone Number (include area code)
E-Mail Address
Extension
Check the appropriate boxes below and summarize your complaint. 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. Please attach a copy of a check stub or W-2 form, if available.
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 (expenses, per diem, etc.)
Remember that the department does not assume your complaint is valid just because you have filled
out 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-E (R. 07/2010)
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