Form Wh-22 - Complaint Form - Bureau Of Labor And Industries Wage And Hour Division Page 2
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1
2OFFICE USE ONLY
BUREAU OF LABOR AND INDUSTRIES
Wage and Hour Division
File # _________________
COMPLAINT FORM
Main File # ____________
DO NOT USE THIS FORM IF YOU WISH TO FILE A CLAIM FOR UNPAID WAGES.
INSTEAD, COMPLETE A WAGE CLAIM FORM.
Please Print
Date:
Name of business:
Name of business owner:
Department/division/branch (if applicable):
Type of business:
Employer’s address:
Employer’s telephone number: (
)
☐
☐
Number of employees:
Is there a union contract?
Yes
No
Check nature of complaint:
☐
Child Labor
Age of Minor:
☐
Failure to receive required rest breaks or meal periods
☐
Are you a tipped food/beverage service employee that has been required by your
employer to waive your meal periods?
☐
Deductions
☐
Final paychecks
☐
Issued paycheck(s) with insufficient funds
☐
Other (irregular pay, personnel records, no check stubs, etc.)
Describe the problem:
Did your employer take any adverse employment action against you because you complained
☐
☐
about a violation of wage and hour laws?
Yes
No Please explain:
Note: Pursuant to the state’s Public Records Law, the complaint form is a public record which may be made available to a
member of the public upon request. However, to the extent permitted by the law, BOLI will not disclose the complainant’s
residential address, personal telephone numbers, and personal email address if the complainant requests that this information
remain confidential. I am submitting my address, telephone numbers, and email address in confidence and request that
they not be disclosed. ☐Yes ☐No
Your name:
Telephone: (
)
Address:
Email:
WH-22 (Rev. 5/17)
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