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

This form is used for complaints under the Pennsylvania Minimum Wage Act of 1968 and the Wage Payment and Collection Law.

Claimant Information
First Name:	*		Area - Daytime Telephone:	*
Initial:			Area - 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:			City:	*
Last Name of Owner:	*		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:	*
			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

Additional Employer Information
Location of where your work took place:	*	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, when was your last date worked:(mm/dd/yyyy):	*
Was your separation:		Voluntary   Involuntary
1. Was there a written contract of employment between you and the named employer?:	*	YES  NO
2. What was your regular pay schedule?:	*	Weekly  Bi-Weeklys  Monthly  Other
If Other, please explain:	*	Please limit to 250 characters or less.
3. Were wages paid to you in the form of a check?:	*	YES  NO
If No, please explain how you were paid. Example: cash, money order, direct deposit, Venmo.:	*	Please limit to 250 characters or less.
4. What was your pay rate?:
Hourly $:	*
Weekly $:	*
Other (please explain):	*	Please limit to 250 characters or less.
5. What is the total amount of wages you are owed?:	*
6. Please enter the following information regarding the wages you are claiming: (pay period ending date / number of hours worked / rate of pay per hour, day, week or other / total gross wages earned / specify if vacation pay, sick leave or commission are owed).: *
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.
7. If known, provide the employer's reason for refusal of payment:	*	Please limit to 1500 characters or less.
8. Have any deductions been made from your pay without your written consent?:	*	YES  NO
If Yes, please explain:	*	Please limit to 1500 characters or less.
9. Do you owe any money to the named employer for any reason?:	*	YES  NO
If Yes, how much? $:	*
10. 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 wages.
I hereby assign the said wages and all penalty wages accruing because of nonpayment thereof, also all liens securing said wages to the Secretary of Labor and Industry of the Commonwealth of Pennsylvania, and any Deputy or Representative authorized to act on the Secretary's behalf, to collect under the provisions of Section 9.1(e) of the Wage Payment and Collection Law or Section 13 of the Pennsylvania Minimum Wage Act, Sec. 333.113.
Once we receive your Wage Complaint Form, we will log it in and assign it to a Labor Investigator and a confirmation email will be sent out. The Bureau will contact you for any further information.
The information shared in this complaint form is confidential.
Auxiliary aides are available by request to individuals with disabilities.
We do not inquire about immigration status.