U.S. DEPARTMENT OF LABOR WAGE AND HOUR COMPLAINT

COMPLAINT TO THE WAGE AND HOUR DIVISION (WHD)

ABOUT THIS FORM

This template is designed to help you prepare and organize information for filing a complaint with the U.S. Department of Labor's Wage and Hour Division (WHD). The WHD enforces federal labor laws including:

• Fair Labor Standards Act (FLSA) - Minimum wage, overtime, child labor
• Family and Medical Leave Act (FMLA) - Unpaid, job-protected leave
• Migrant and Seasonal Agricultural Worker Protection Act (MSPA)
• Employee Polygraph Protection Act (EPPA)
• Davis-Bacon and Related Acts - Prevailing wages on federal contracts
• Service Contract Act
• H-1B visa worker protections

HOW TO FILE WITH THE DOL

Online: www.dol.gov/agencies/whd/contact/complaints
Phone: 1-866-4-US-WAGE (1-866-487-9243)
In Person: Visit your local WHD office
By Mail: Send to your regional WHD office

Important Notes:
- Filing is FREE
- Complaints are CONFIDENTIAL
- Immigration status does not affect your right to file
- You are protected from RETALIATION for filing

PART 1: COMPLAINANT INFORMATION

Full Legal Name: _______________________________________________

Other Names Used: _______________________________________________

Current Address:
- Street: _______________________________________________
- City: _________________________ State: _____ ZIP: ___________

Mailing Address (if different):
- Street: _______________________________________________
- City: _________________________ State: _____ ZIP: ___________

Contact Information:
- Home Phone: _________________________
- Cell Phone: _________________________
- Email: _________________________
- Preferred Contact Method: ☐ Home Phone ☐ Cell Phone ☐ Email

Best Time to Contact: ☐ Morning ☐ Afternoon ☐ Evening

May WHD Leave a Message?
- Home Phone: ☐ Yes ☐ No
- Cell Phone: ☐ Yes ☐ No
- Email: ☐ Yes ☐ No

Preferred Language: ☐ English ☐ Spanish ☐ Other: _______________

Interpreter Needed: ☐ Yes ☐ No

PART 2: EMPLOYER INFORMATION

Employer Name (Legal Name): _______________________________________________

Doing Business As (DBA): _______________________________________________

Employer Address:
- Street: _______________________________________________
- City: _________________________ State: _____ ZIP: ___________

Employer Phone: _________________________

Employer Fax: _________________________

Employer Website: _________________________

Type of Business: _______________________________________________
(e.g., restaurant, retail, construction, manufacturing, healthcare)

What does the business do?
_______________________________________________

Owner Name(s):
1. _______________________________________________
2. _______________________________________________

Manager/Supervisor Name: _______________________________________________

Human Resources Contact: _______________________________________________

Payroll Manager/Contact: _______________________________________________

Approximate Number of Employees: _________________________

Does the employer have multiple locations?
☐ Yes ☐ No

If yes, list other locations:
_______________________________________________
_______________________________________________

PART 3: YOUR EMPLOYMENT INFORMATION

Job Title(s): _______________________________________________

Department: _______________________________________________

Work Location Address (if different from employer address):
_______________________________________________

Date of Hire: _________________________

Date Employment Ended (if applicable): _________________________

Are you still employed there?
☐ Yes ☐ No

If no, reason for leaving:
☐ Fired/Terminated
☐ Laid Off
☐ Resigned
☐ Other: _________________________

Employment Type:
☐ Full-time
☐ Part-time
☐ Temporary
☐ Seasonal

How were you classified?
☐ Employee
☐ Independent Contractor
☐ Unsure

PART 4: PAY INFORMATION

How were you paid?
☐ Hourly
☐ Salary
☐ Piece rate
☐ Commission
☐ Day rate
☐ Tips
☐ Combination: _________________________

Rate of Pay:
- Hourly rate: $__________ per hour
- Salary: $__________ per ☐ week ☐ bi-weekly ☐ month ☐ year
- Other: _________________________

Pay Frequency:
☐ Weekly
☐ Bi-weekly (every two weeks)
☐ Semi-monthly (twice per month)
☐ Monthly

Regular Payday: _________________________

How were you paid?
☐ Check
☐ Direct deposit
☐ Cash
☐ Payroll card
☐ Other: _________________________

Did you receive pay stubs?
☐ Yes ☐ No ☐ Sometimes

PART 5: WORK HOURS INFORMATION

Typical Work Schedule:

Average Hours Per Week: _________________________

Did you work more than 40 hours in any week?
☐ Yes ☐ No

If yes, how often?
☐ Every week
☐ Most weeks
☐ Sometimes
☐ Rarely

How were your hours recorded?
☐ Time clock/electronic system
☐ Paper time cards
☐ Sign-in sheet
☐ Employer estimated/tracked hours
☐ No time tracking
☐ Other: _________________________

PART 6: TYPE OF VIOLATION (Check All That Apply)

Minimum Wage Violations

☐ Paid less than federal minimum wage ($7.25/hour)
☐ Paid less than state/local minimum wage ($__________)
☐ Not paid for all hours worked
☐ Deductions reduced pay below minimum wage

Overtime Violations

☐ Not paid overtime (time and a half) for hours over 40/week
☐ Paid incorrect overtime rate
☐ Overtime hours not recorded
☐ Misclassified as exempt from overtime

Off-the-Clock Work

☐ Required to work before clocking in
☐ Required to work after clocking out
☐ Work during unpaid meal breaks
☐ Unpaid training or meetings
☐ Time shaving (employer adjusted time records)

Tip Violations

☐ Employer kept tips
☐ Management took tips
☐ Invalid tip pool (includes non-tipped employees while employer takes tip credit)
☐ Tip credit not explained before employment
☐ Tips + cash wage did not equal minimum wage

Worker Misclassification

☐ Classified as independent contractor but treated as employee
☐ Classified as exempt but duties don't meet exemption requirements

Child Labor Violations

☐ Minor worked too many hours
☐ Minor worked during prohibited hours
☐ Minor performed hazardous work

Other FLSA Violations

☐ Retaliation for complaining about wages
☐ Failure to keep proper records
☐ Other: _________________________

FMLA Violations (Family and Medical Leave)

☐ Denied FMLA leave request
☐ Fired/disciplined for taking FMLA leave
☐ FMLA leave not counted correctly
☐ Job not restored after FMLA leave
☐ Other: _________________________

Other Federal Wage Laws

☐ Davis-Bacon Act (prevailing wages on federal construction)
☐ Service Contract Act
☐ H-1B visa worker violation
☐ Migrant/seasonal worker violation (MSPA)
☐ Other: _________________________

PART 7: DETAILED DESCRIPTION OF VIOLATION

Describe what happened:
(Be specific: include dates, times, amounts, names of supervisors involved, what was said or done)

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

When did the violation start? _________________________

When did the violation end? _________________________ ☐ Still ongoing

How often did the violation occur?
☐ Every pay period
☐ Most pay periods
☐ Sometimes
☐ One-time incident

PART 8: CALCULATION OF WAGES OWED

Minimum Wage Owed:

Subtotal Minimum Wage Shortage: $_________________________

Overtime Owed:

Subtotal Overtime Shortage: $_________________________

Other Wages Owed:
- Tips withheld: $_________________________
- Off-the-clock work: $_________________________
- Other: $_________________________

TOTAL ESTIMATED WAGES OWED: $_________________________

PART 9: EVIDENCE AND DOCUMENTATION

Do you have any of the following? (check all that apply)

☐ Pay stubs/wage statements
☐ Time records/cards
☐ Work schedules
☐ Personal log of hours worked
☐ Employment contract/offer letter
☐ Employee handbook
☐ Emails or text messages about work/hours
☐ Photos of schedules or time records
☐ Bank statements showing deposits
☐ Tax forms (W-2, 1099)
☐ Other: _________________________

Note: You do NOT need documents to file a complaint. WHD can investigate without them.

PART 10: OTHER AFFECTED EMPLOYEES

Are other employees affected by this violation?
☐ Yes ☐ No ☐ Unknown

If yes:
- Approximate number: _________________________
- Job titles: _______________________________________________

Do you have contact information for any other affected employees?
☐ Yes ☐ No

If yes, provide names and contact info (optional):
1. _______________________________________________
2. _______________________________________________
3. _______________________________________________

PART 11: PREVIOUS COMPLAINTS

Have you complained to your employer about these issues?
☐ Yes ☐ No

If yes:
- Date: _________________________
- To whom: _________________________
- Response: _______________________________________________

Have you filed a complaint with any other agency?
☐ Yes ☐ No

If yes:
- Agency: _________________________
- Date filed: _________________________
- Case/claim number: _________________________
- Status: _________________________

Have you consulted with an attorney?
☐ Yes ☐ No

If yes:
- Attorney name: _________________________
- Phone: _________________________

PART 12: RETALIATION

Have you experienced retaliation for complaining about wage issues?
☐ Yes ☐ No

If yes, describe:
☐ Fired/Terminated
☐ Demoted
☐ Hours reduced
☐ Pay reduced
☐ Schedule changed unfavorably
☐ Written warning/discipline
☐ Harassment
☐ Threats (including immigration-related threats)
☐ Other: _________________________

Date(s) of retaliation: _________________________

Describe what happened:
_______________________________________________
_______________________________________________

Note: It is ILLEGAL for employers to retaliate against employees for filing a DOL complaint. Report any retaliation immediately.

PART 13: STATE-SPECIFIC NOTES

State Where Work Was Performed: _________________________

CALIFORNIA

• California has higher minimum wage and additional protections
• May also file with California DLSE for state law violations
• California claims may include meal/rest break violations (not covered by FLSA)

TEXAS

• Texas follows federal minimum wage ($7.25/hour)
• Texas Payday Law covers wage payment issues
• May also file with Texas Workforce Commission

FLORIDA

• Florida minimum wage is higher than federal ($14.00/hour in 2026)
• File with DOL for FLSA violations
• No state wage enforcement agency for most claims

NEW YORK

• New York has higher minimum wage varying by region
• May also file with NY Department of Labor
• Additional state protections may apply

PART 14: CONSENT AND AUTHORIZATION

Consent to Investigate:

☐ I authorize the U.S. Department of Labor, Wage and Hour Division to investigate this complaint, contact my employer, review records, and take necessary enforcement action.

Confidentiality:

☐ I understand that the DOL will keep my complaint confidential and will not reveal my name to my employer without my permission, except as required to pursue an investigation or if ordered by a court.

Retaliation Notice:

☐ I understand that it is illegal for my employer to retaliate against me for filing this complaint, and I should report any retaliation to WHD immediately.

PART 15: DECLARATION

I declare under penalty of perjury that the information I have provided in this complaint is true and correct to the best of my knowledge and belief.

Signature: _______________________________________________

Printed Name: _______________________________________________

Date: _________________________

PART 16: HOW TO SUBMIT THIS COMPLAINT

Option 1: Online
Visit: www.dol.gov/agencies/whd/contact/complaints
Complete the online complaint form

Option 2: Phone
Call: 1-866-4-US-WAGE (1-866-487-9243)
Available Monday-Friday, 8am-5pm local time
TTY: 1-877-889-5627

Option 3: In Person
Find your local WHD office: www.dol.gov/agencies/whd/contact/local-offices

Option 4: Mail
Send to your regional WHD office (addresses available at link above)

WHAT HAPPENS AFTER YOU FILE

1. Intake: WHD staff will review your complaint
2. Contact: An investigator may contact you for more information
3. Investigation: WHD will investigate the employer
4. Resolution: WHD may:
   - Order the employer to pay back wages
   - Assess civil money penalties
   - File lawsuit on your behalf
   - Refer for criminal prosecution (in serious cases)
5. Notification: You will be informed of the outcome

Typical Timeline: Investigations can take several weeks to months depending on complexity.

YOUR RIGHTS

• Confidentiality: Your identity is protected
• No Cost: Filing is free
• Immigration Status: You have rights regardless of immigration status
• No Retaliation: Employers cannot fire or punish you for filing
• Recovery: You may recover back wages and liquidated damages

CHECKLIST BEFORE FILING

☐ Personal information complete
☐ Employer information complete
☐ Type of violation identified
☐ Dates and details of violations documented
☐ Approximate wages owed calculated
☐ Contact information current
☐ Signature and declaration complete

RESOURCES

• DOL Wage and Hour Division: www.dol.gov/agencies/whd
• File a Complaint: www.dol.gov/agencies/whd/contact/complaints
• Find Local Office: www.dol.gov/agencies/whd/contact/local-offices
• Minimum Wage: www.dol.gov/agencies/whd/minimum-wage
• Overtime: www.dol.gov/agencies/whd/overtime
• Worker.gov: www.worker.gov

This template is provided for informational purposes only and does not constitute legal advice. For advice specific to your situation, consult with a qualified employment attorney.