Non-Payment Of Wage And Workplace Complaint Form- Page 1 Page 2
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Non-Payment of Wage and Workplace Complaint Form- Page 2
Name of Employee: _______________________________________________________________________________
Do you speak English? Yes
No
What language would you prefer we contact you in?
What type of work did you perform?
Name of employer
Are you currently working for this employer? Yes
No ___
If applicable, reason for end of employment? Quit
Discharged ____
Did you sign a contract with the employer? Yes
No
Is an attorney representing you? Yes
No
Has a community organization or union helped you file this complaint? Yes
No
If yes, please provide name(s) of the attorney, organization, or union; as well as a contact person, address, and
phone number.
Did you ask to get paid the wages you are owed? Yes
No
If yes, what was the employer’s response?
Have you taken any other action against the employer regarding this problem? Yes
No
If yes, please explain.
An employer does not have the right to threaten, discriminate, or retaliate against you because of your efforts to collect
wages. If this has happened to you, please explain.
Wage/Workplace Complaint Form
Page 3 of 4
Rev. 12/2008
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