Wage Theft Complaint | English

Your Contact Information | * Required Fields

First Name *

Middle Name

Last Name *

Address

City

State

Zip

Phone Number *

Phone Extension

E-mail Address *

Company or Employer Information | * Required Fields

Company Name or Employer *

Address

City

State

Zip

Phone Number *

Phone Extension

E-mail Address *

Occurrence Details | * Required Fields

Pay Period Begin

Pay Period End

Date Wages to be Paid

Complaint

Please provide details about your claim. When were the wages earned? When were you to be paid?
Please provide a brief description of the work performed and where it was performed. (Limit 4000 characters)

Total Wages Owed *

Written Demand

Have you sent the employer a written demand for payment of wages?

Captcha *