Complaint Form - New York State Attorney
Download a blank fillable Complaint Form - New York State Attorney in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Complaint Form - New York State Attorney with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2OFFICE OF ATTORNEY GENERAL ERIC T. SCHNEIDERMAN
STATE OF NEW YORK DEPARTMENT OF LAW
COMPLAINT FORM
LABOR BUREAU
TH
120 Broadway, 26
Floor, New York, NY 10271-0332 • Tel. (212) 416-8700 • Fax (212) 416-8694
EMPLOYEE/COMPLAINANT
YOUR NAME
DAYTIME PHONE NUMBER
HOME PHONE NUMBER
STREET ADDRESS
WHAT IS THE BEST TIME TO REACH YOU BY PHONE?
CITY/TOWN
STATE
ZIP CODE
EMAIL ADDRESS
YOUR EMPLOYER(S)
TELEPHONE NUMBER
NAME OF YOUR EMPLOYER
CITY/TOWN
STATE
ZIP CODE
STREET ADDRESS
OWNER'S NAME(S)
SUPERVISOR'S NAME
HOW MANY PEOPLE WORK FOR THIS EMPLOYER AT ALL LOCATIONS?
5 O R F E W E R
6
14
15 to 49
50+
TO
YOUR JOB
JOB TITLE/ DESCRIPTION
DATES OF EMPLOYMENT
WHAT HOURS DO YOU WORK?
DO YOU GET A MEAL BREAK?
WHAT DAYS DO YOU WORK? (CHECK THOSE THAT APPLY)
START ______
END
______
YES
_____
NO
_____
MON.
____
TUES.
____
WED.
____
THURS.
____
FRI.
____
SAT.
____
SUN. ____
WHAT IS YOUR RATE OF PAY?
$ ___________
PER
H O U R ,
D A Y ,
W E E K ,
___________
ARE YOU PAID A HIGHER RATE OF PAY FOR HOURS OVER 40 IN A WEEK? YES__
NO
___
HOW OFTEN ARE YOU PAID? DAILY / WEEKLY / OTHER
DO YOU RECEIVE TIPS?
ARE YOU PAID IN CASH OR CHECK OR BOTH?
DO YOU RECEIVE HEALTH OR OTHER BENEFITS?
YES_____
NO
_____
CASH
________
CHECK
_____
___
BOTH_
_______
HEALTH
_______
OTHER
_______
DO YOU RECEIVE A W-2? YES_____
NO
_____
HAVE YOU COMPLAINED TO ANYONE ELSE OR FILED A LAWSUIT REGARDING THE
ISSUES YOU ARE COMPLAINING ABOUT? PLEASE PROVIDE DETAILS.
DOES IT LIST ALL YOUR WAGES? YES_____ NO _____
YOUR COMPLAINT
TYPE OF COMPLAINT. I WAS NOT PAID WAGES, FIRED, INJURED, HARASSED (PROVIDE DETAILS BELOW AND ON THE BACK OF PAGE)
PLEASE PROVIDE HERE AND ON THE NEXT PAGE A BRIEF DESCRIPTION OF YOUR COMPLAINT,
INCLUDING NAMES OF OTHER EMPLOYEES AND THEIR CONTACT INFORMATION
___________________________________________________________________________________________
___________________________________________________________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Octf001 - Complaint Form - State Of New York Department Of Law Office Of The Attorney General Eric T. Schneiderman
Legal
Form Tt-102 - New York State Resident Affidavit Form - New York State Department Of Taxation And Finance - New York
Legal
Form St-101 - New York State And Local Annual Sales And Use Tax Return Form - New York State Department Of Taxation And Finance
Financial
Related Categories
Parent category: Legal