FLSA MINIMUM WAGE COMPLAINT

COMPLAINT FOR MINIMUM WAGE VIOLATIONS UNDER THE FAIR LABOR STANDARDS ACT

PART 1: COMPLAINANT INFORMATION

Full Legal Name: _______________________________________________

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

Contact Information:
- Phone: _________________________
- Email: _________________________
- Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

Date of Birth: _________________________

Social Security Number (Last 4 digits): XXX-XX-________
(Full SSN may be required by DOL; provide only if requested)

PART 2: EMPLOYER INFORMATION

Employer Name: _______________________________________________

Doing Business As (DBA): _______________________________________________

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

Employer Phone: _________________________

Employer Website: _________________________

Type of Business/Industry: _______________________________________________

FEIN (if known): _______________________________________________

Name of Owner/Supervisor: _______________________________________________

Estimated Number of Employees: _________________________

Annual Business Revenue (if known):
☐ Under $500,000
☐ $500,000 or more
☐ Unknown

PART 3: EMPLOYMENT DETAILS

Date of Hire: _________________________

Date Employment Ended (if applicable): _________________________

Current Employment Status:
☐ Currently Employed
☐ Terminated/Discharged
☐ Resigned
☐ Laid Off

Job Title: _______________________________________________

Job Duties Description:
_______________________________________________
_______________________________________________

Pay Arrangement:
☐ Hourly: $__________ per hour
☐ Salary: $__________ per _____________
☐ Piece Rate: $__________ per _____________
☐ Commission Only
☐ Day Rate: $__________ per day
☐ Tipped Employee: $__________ per hour (cash wage)
☐ Other: _________________________

Method of Payment:
☐ Check ☐ Direct Deposit ☐ Cash ☐ Payroll Card ☐ Other: ___________

PART 4: MINIMUM WAGE VIOLATION DETAILS

Current Federal Minimum Wage: $7.25 per hour

Applicable State Minimum Wage: $__________ per hour
(Note: The higher of federal or state minimum wage applies)

Type of Minimum Wage Violation (check all that apply):

☐ Paid below federal minimum wage ($7.25/hour)
☐ Paid below applicable state minimum wage
☐ Illegal deductions reduced wages below minimum wage
☐ Required to work "off the clock" without pay
☐ Time shaving/falsification of time records
☐ Improper tip credit application
☐ Required to pay for uniforms/equipment reducing wages below minimum
☐ Required to pay for breakage/shortages reducing wages below minimum
☐ Paid sub-minimum wage without proper certification (youth/disability)
☐ Not paid for all hours worked (training, meetings, travel)
☐ Paid by piece rate that averaged below minimum wage
☐ Other: _________________________

Time Period of Violation:
- Start Date: _________________________
- End Date: _________________________ (or ☐ Ongoing)

PART 5: HOURS AND WAGE CALCULATION

Average Hours Worked Per Week: _________________________

Hours Per Day (typical):
| Day | Start Time | End Time | Unpaid Breaks | Total Hours |
|-----|------------|----------|---------------|-------------|
| Mon | __________ | ________ | _____________ | ___________ |
| Tue | __________ | ________ | _____________ | ___________ |
| Wed | __________ | ________ | _____________ | ___________ |
| Thu | __________ | ________ | _____________ | ___________ |
| Fri | __________ | ________ | _____________ | ___________ |
| Sat | __________ | ________ | _____________ | ___________ |
| Sun | __________ | ________ | _____________ | ___________ |

Minimum Wage Calculation:

Total Minimum Wage Shortage: $_________________________

PART 6: TIPPED EMPLOYEE SECTION (IF APPLICABLE)

Are you a tipped employee?
☐ Yes ☐ No

If No, skip to Part 7

Cash Wage Paid by Employer: $__________ per hour

Federal Minimum Cash Wage for Tipped Employees: $2.13 per hour

Tip Credit Claimed by Employer: $__________ per hour

Average Tips Received per Hour: $_________________________

Did employer inform you of tip credit provisions before claiming credit?
☐ Yes ☐ No

Tip Pool Participation:
☐ Not in a tip pool
☐ Required tip pool - share tips with: _________________________
☐ Voluntary tip sharing

Tip Credit Violations (check all that apply):

☐ Combined cash wage + tips did not equal minimum wage
☐ Employer did not inform me of tip credit provisions
☐ Required to share tips with management/supervisors
☐ Required to share tips with non-tipped employees (while employer takes tip credit)
☐ Employer retained portion of tips
☐ Tip pool includes prohibited employees
☐ Performed non-tipped duties for more than 20% of work time or 30 continuous minutes
☐ Other: _________________________

PART 7: ILLEGAL DEDUCTIONS

Did your employer make deductions that reduced your pay below minimum wage?
☐ Yes ☐ No

Types of Deductions (check all that apply):

☐ Uniforms or uniform cleaning
☐ Tools or equipment
☐ Cash register shortages
☐ Breakage or damage
☐ Cost of meals (without consent)
☐ Transportation costs
☐ Training costs
☐ Docking for customer walkouts
☐ Credit card processing fees (from tips)
☐ Other: _________________________

Total Illegal Deductions: $_________________________

PART 8: OFF-THE-CLOCK WORK

Were you required to perform work without pay?
☐ Yes ☐ No

Types of Unpaid Work (check all that apply):

☐ Work before clocking in (opening duties, setup)
☐ Work after clocking out (closing duties, cleanup)
☐ Work during unpaid meal breaks
☐ Required training without pay
☐ Required meetings without pay
☐ Work from home without pay
☐ Answering calls/emails during off hours
☐ Waiting time (on employer's premises)
☐ Travel time between job sites
☐ Other: _________________________

Estimated Unpaid Hours per Week: _________________________

Total Estimated Unpaid Hours: _________________________

PART 9: DETAILED DESCRIPTION OF VIOLATION

Describe in detail how the minimum wage violation occurred:
(Include specific examples, dates, amounts, and circumstances)

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

PART 10: SUPPORTING DOCUMENTATION

Documents in Your Possession (check all that apply):

☐ Pay stubs/wage statements
☐ Time cards/time records
☐ Work schedules
☐ Employment contract/offer letter
☐ Employee handbook/policy manual
☐ Personal log of hours worked
☐ Bank statements showing deposits
☐ Text messages/emails about work
☐ Photographs (uniforms, equipment, schedules)
☐ Tip records
☐ Deduction records
☐ Other: _________________________

PART 11: OTHER AFFECTED EMPLOYEES

Are other employees experiencing similar violations?
☐ Yes ☐ No ☐ Unknown

If yes:
- Estimated number of affected employees: _________________________
- Job titles affected: _______________________________________________
- Would they be willing to participate in complaint? ☐ Yes ☐ No ☐ Unknown

PART 12: PRIOR COMPLAINTS AND RETALIATION

Have you complained to your employer about minimum wage violations?
☐ Yes ☐ No

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

Have you experienced retaliation?
☐ Yes ☐ No

If yes, type of retaliation:
☐ Termination
☐ Demotion
☐ Reduced hours
☐ Reduced pay
☐ Unfavorable schedule change
☐ Hostile treatment
☐ Threats
☐ Other: _________________________

PART 13: DAMAGES CALCULATION

Back Wages Calculation:

Total minimum wage shortage per week: $_________________________

Number of weeks affected: _________________________

Total Back Wages Owed: $_________________________

Liquidated Damages (equal to back wages): $_________________________

TOTAL DAMAGES SOUGHT: $_________________________

(Under FLSA, employees may recover liquidated damages equal to the unpaid wages, unless employer can prove good faith and reasonable grounds)

PART 14: STATUTE OF LIMITATIONS

IMPORTANT:
- Standard FLSA claims: 2 years from date of violation
- Willful violations: 3 years from date of violation

Date of earliest violation: _________________________

Is the violation willful?
☐ Yes - Employer knew or showed reckless disregard for the law
☐ No - Employer may have had good faith belief
☐ Unknown

PART 15: STATE-SPECIFIC NOTES

CALIFORNIA

• 2026 Minimum Wage: $16.50/hour (statewide); higher in some cities
• No tip credit allowed in California
• California prohibits most wage deductions
• 4-year statute of limitations
• File with Division of Labor Standards Enforcement (DLSE)
• Additional penalties under Labor Code § 1194.2

TEXAS

• Texas follows federal minimum wage ($7.25/hour)
• Texas Payday Law covers wage payment
• File with Texas Workforce Commission
• Federal FLSA claims may be filed with DOL or in court

FLORIDA

• 2026 Minimum Wage: $14.00/hour (increasing annually)
• Tipped minimum wage: $10.98/hour
• Florida Constitution Article X, Section 24
• File with U.S. DOL (no state enforcement agency)

NEW YORK

• 2026 Minimum Wage: Varies by region and employer size
• NYC: $16.50/hour
• Long Island & Westchester: $16.50/hour
• Remainder of state: $15.50/hour
• 6-year statute of limitations under NY Labor Law
• File with NY Department of Labor

PART 16: FILING OPTIONS

Choose how to pursue your claim:

☐ U.S. Department of Labor, Wage and Hour Division
- Phone: 1-866-4-US-WAGE (1-866-487-9243)
- Website: www.dol.gov/agencies/whd
- Free to file; DOL investigates
- Confidential process

☐ State Labor Agency
- State: _________________________
- Agency: _________________________
- May provide additional remedies

☐ Private Lawsuit
- May recover wages, liquidated damages, attorney fees
- Consult with employment attorney
- Must file within statute of limitations

PART 17: DECLARATION

I declare under penalty of perjury under the laws of the United States of America that the foregoing information is true and correct to the best of my knowledge and belief.

I understand that filing a false claim may subject me to civil and criminal penalties. I authorize the investigation of this complaint.

Complainant Signature: _______________________________________________

Printed Name: _______________________________________________

Date: _________________________

PART 18: ATTORNEY INFORMATION (IF APPLICABLE)

Attorney Name: _______________________________________________

Firm Name: _______________________________________________

Address: _______________________________________________

Phone: _________________________ Email: _________________________

Bar Number: _________________________

PRE-FILING CHECKLIST

☐ Calculated total wages owed
☐ Gathered all supporting documents
☐ Made copies of all materials
☐ Verified statute of limitations
☐ Reviewed state-specific requirements
☐ Considered legal consultation
☐ Protected against potential retaliation

RESOURCES

• U.S. DOL Wage and Hour Division: www.dol.gov/agencies/whd
• Minimum Wage Information: www.dol.gov/agencies/whd/minimum-wage
• State Minimum Wage Laws: www.dol.gov/agencies/whd/minimum-wage/state
• Worker.gov: www.worker.gov

This template is provided for informational purposes only. Employment law varies by jurisdiction and individual circumstances. Consult with a qualified employment attorney for advice specific to your situation.