Form Ls-119-E - Labor Standards Complaint Page 2

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Employment and Wage Information
Have You asked for your wages?
What date did you ask?
Yes
No
What did the employer say?
Hourly Rate of Pay
Salary
Commission
Piece Rate/Flat rate
Per
Per
Per
How often were you paid?
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Other (Specify)
Did you receive tips?
Yes
No
Average amount of tips per day?
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 week?
Does the Employer keep time records?
usually work?
Yes
No
Check all the boxes that apply to the types of records you have kept:
Hours worked (If checked submit with complaint.)
Check stubs
Deduction Slips
No records
Give your job title and briefly describe the kind of work you did
Work location street address
City
State
Zip Code
County where you worked
You must complete the next 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 bankruptcy or
Have you filed this claim in court?
Is there a union to represent you?
receivership?
Yes
No
Yes
No
Yes
No
By providing my signature below statements made on this complaint are true to the best of my
knowledge. This Complaint is an open record and May 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.
Complaint Signature (Required)
Date Signed
Child Labor – Complete if you were under age 18 at time of employment.
Was a work permit issued?
If yes, enter date permit was issued
Yes
No
Y
Are you still in high school?
es
No
Are you enrolled in any of the following:
Alternative School
GED/HSED Program
If no, did you graduate?
Yes
No
Home Schooling
Charter School
If yes, date you graduated:
Name of current or last school attended
Address of current or last school attended
2

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