Department of Labor & Industry - Bureau of Labor Law Compliance - Prevailing Wage Complaint

This form is used for complaints under the Pennsylvania Prevailing Wage Act of 1961.

Claimant Information
First Name:	*		Area Code - Daytime Telephone:	*
Initial:			Area Code - Evening Telephone:
Last Name:	*		Fax:
Address - Line 1:	*		E-Mail:
Address - Line 2:
City:	*
State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:	*

Employer Information
First Name of Contact Person:			Company Name:	*
Initial:			Area - Daytime Telephone:	*
Last Name of Contact Person:			Address Line 1:	*
First Name of Owner:			Address Line 2:
Initial:			State:	*	---Select--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Last Name of Owner:			City:	*
			Zip:	*
			County:		---Select--- None Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York Out of State

Project Details
Project Name:	*
County:	*	---Select--- None Adams Allegheny Armstrong Beaver Bedford Berks Blair Bradford Bucks Butler Cambria Cameron Carbon Centre Chester Clarion Clearfield Clinton Columbia Crawford Cumberland Dauphin Delaware Elk Erie Fayette Forest Franklin Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montgomery Montour Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York Out of State
Location:	*	Please limit to 1500 characters or less.
Type of Work Performed:	*	Please limit to 2500 characters or less.

Complaint Details
Date Hired:(mm/dd/yyyy)	*
Are you still employed by the named employer?:	*	YES NO
If no, give last date worked (mm/dd/yyyy):	*
Was your termination:	*	Voluntary Involuntary
1. Was there a written contract between you and the named employer?:	*	YES NO
2. Were you notified by the named employer as to when and where you would be paid?:	*	YES NO
3. What was your regular payday to be?:	*	Weekly Bi-Weekly Monthly Other
If Other, please explain:	*
4. Were wages paid to you in a form other than a check?:		YES NO
If Yes, please explain:
5. What was the latest rate of pay agreed upon between you and the named employer?:
Enter hourly rate $:	*
6. What are the TOTAL wages claimed by you? $:	*
7. Please enter the following information regarding the wages you are claiming: (week ending date, number of hours worked, rate of pay per hour, day, week or other, total gross wages earned, and specify if vacation pay, sick leave or commission).
Please limit to 2500 characters or less.
NOTE: Failure to provide detailed information in the space provided above may make it impossible to pursue this claim on your behalf.
8. Did the named employer refuse to pay these wages?	*	YES NO
If Yes, state employer's reason for refusal:	*	Please limit to 1500 characters or less.
9. Do you and the named employer agree as to the amount of wages due to you?:	*	YES NO
If No, what amount does the named employer acknowledge as being due? $:	*
10. Has the named employer given you written confirmation of the amount due to you?:	*	YES NO
11. Has the named employer offered to pay you the amount to be due?:	*	YES NO
If Yes, have you accepted the amount offered?:	*	YES NO
12. Have you agreed in writing to any deductions?:	*	YES NO
If Yes, please list deductions:	*	Please limit to 2500 characters or less.
13. Have any deductions been made without your written agreement?:	*	YES NO
If Yes, please explain:	*	Please limit to 2500 characters or less.
14. Do you owe any money to the named employer for any reason?:	*	YES NO
If Yes, how much? $:	*
15. Are you covered under a Collective Bargaining Agreement?:	*	YES NO
If Yes, list the name and address of the union:		Please limit to 1500 characters or less.
You may enter additional information here to summarize related information and wage computations.		Please limit to 2500 characters or less.
I hereby certify that to the best of my knowledge and belief, this is a true statement of facts relating to the above claim of unpaid prevailing wages.
The Bureau will contact you for any further information.