Form Erd-9850 - Wisconsin Prevailing Wage Rate Complaint

[5] ALLEGEDLY AGGRIEVED EMPLOYE DATA:

Date Employment Began with Employer

Date Employment Ended (If a former employe)

Normal Trade/Occupation

Normal Rate of Pay

o Per Hour

o Per Week

Apprentice?

Date Indentured

o Yes

o No

Describe BOTH the kind of work you normally performed AND the tools you normally used.

____________________________________________________________________________________________________

Does your employer normally provide you with ANY fringe benefits, such as

health insurance, pension, paid vacation, profit sharing, IRA, etc.?..................o Yes o No

If yes, indicate below the specific fringe benefits provided.

If yes, did the employer pay the entire cost of such benefits?......................... o Yes o No

If no, indicate the approximate cost you pay AND your employer pays for EACH benefit.

____________________________________________________________________________________________________

: Please enter the following information for ONLY the PUBLIC WORKS project(s) on which the

[6] PROJECT INFORMATION

employer allegedly committed the previously indicated violation(s). If project information is not entered no investigation will

be conducted.

Name of Project

Location

Determination Number

_________________________________

_____________________________

_______________________________

_________________________________

_____________________________

_______________________________

_________________________________

_____________________________

_______________________________

_________________________________

_____________________________

_______________________________

Describe BOTH the work you performed and date(s) you worked on the above named project(s):

____________________________________________________________________________________________________

How much were you paid per hour on the project(s) named above? $___________________

o Yes

o No

Did you ever work any overtime?...............................… ......

o Yes

o No

Did you receive your regular fringe benefits?.................… ....

o Yes

o No

Were any hours “ banked” for use at a future date?..........… ...

o Yes

o No If yes, send them with this form.

Did you keep any records of the hours you worked?............

o Yes

o No If yes, send them with this form.

Did you keep your check stubs?.........................................

[7] CALCULATIONS:

Do you owe your employer any money? o Yes o No If yes, how much and for what? $_______________________

Did you ask your employer for your back wages? o Yes o No If yes, when did you ask? ______________________

How much do you believe the employer owes you? $__________________. Indicate how you arrived at this amount:

____________________________________________________________________________________________________

The statements and information provided above are true to the best of my knowledge. I understand that it is my responsibility to

prove the alleged violation(s) indicated and that: (1) this complaint is an open record under the provisions of Wisconsin’ s Open

Records Law and a copy of it will be provided to the employer; (2) Section 111.322(2m), Stats., prohibits retaliation against an

employe by an employer for most labor standards complaints filed with this department; and, (3) if the employer is found to be in

compliance with all applicable labor standards regulations, I agree to pay the DWD the actual cost of the investigation or, as a third

party complainant, a MINIMUM OF $250, or the actual cost of the investigation, whichever is greater.

Complainant Signature

Title (Optional)

Organization You Represent, if any

Date Signed

Form Erd-9850 - Wisconsin Prevailing Wage Rate Complaint - 2000 Page 2

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