Form Erd-9850 - Wisconsin Prevailing Wage Rate Complaint

WISCONSIN PREVAILING WAGE RATE COMPLAINT

This form MUST be used to file ANY complaint regarding an alleged violation of s. 66.293 or s. 103.49, Stats., or Ch. DWD 290 of the Wisconsin

Administrative Code. The filing of this form does not require this department to conduct an investigation to determine the validity of your complaint. It is

the complainant’ s responsibility to provide proof of the validity of his/her complaint. Any form that is not properly completed will be returned to the

complainant. Enclose a separate sheet of paper if you need additional space. Return ALL completed forms and evidence to: Equal Rights Division,

Labor Standards Bureau, P.O. Box 8928, Madison, WI 53708. Personal information you provide may be used for secondary purposes pursuant to

Wisconsin Privacy Law, s. 15.04(1)(m), Stats.

[1] COMPLAINANT INFORMATION: Please type or print all information.

Name

Social Security Number (optional)

Mailing Address

City

State

Zip Code

Home Telephone

Work Telephone

(

)

(

)

[2] EMPLOYER INFORMATION:

Business Name

Owner Name

Mailing Address

City

State

Zip Code

Business Telephone

(

[3] DETAILED COMPLAINANT INFORMATION:

I am a: o Current Employe

o Former Employe

o State or municipal official

o Other

o Union representative (If you are a union representative, do you presently represent any of the employees that work for the

o Yes o No

employer indicated above?).........................................

o Yes o No

Has the employer filed bankruptcy?................................................

o Yes o No

Is the employer still in business?....................................................

Have you filed a similar complaint regarding this same matter with the U.S. Department of Labor or any other state agency?

o Yes o No If yes, which one? _____________________________________________________________________

o Yes o No

Have you retained an attorney to resolve this matter?.......................

o Yes o No If yes, which local?__________

Are you represented by a local union?.............................................

o Yes o No

Did you file a grievance with the local union regarding this matter?.....

If the COMPLAINANT indicated in (1) above has NEVER been employed by the EMPLOYER indicated in (2), the

complainant MUST provide the name, address and telephone number of an allegedly aggrieved employe and MUST

complete the remainder of this form to the best of his/her ability before this complaint will be investigated. Under these

circumstances a complaint will only be investigated for the allegedly aggrieved employe indicated below. A separate form

must be completed for EACH allegedly aggrieved employe.

Name

Mailing Address

City

State

Zip Code

Home Telephone

(

)

[4] ALLEGED VIOLATION(S): Check the appropriate box(es) and briefly explain the nature of the wage and hour violation(s) allegedly

committed by the employer. Only those violations checked will be investigated:

o Straight Time

o Travel Time

o Weekly Overtime

o Improper Classification

o Banked Hours

o Kickback

o Saturday/Sunday/Holiday Overtime

o Fringe Benefits

o Retaliation

o Improper Ratioo Apprenticeship

o Wages Owed Over 30 Days

o Payroll Records

o Daily Overtime o Did Not Receive Last Paycheck

o Illegal/Non-listed Deductions

______________________________________________________________________________________________________________

YOU MUST COMPLETE THE BACK OF THIS FORM

ERD-9850 R. 01/00

Form Erd-9850 - Wisconsin Prevailing Wage Rate Complaint - 2000

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