EMPLOYEE MISCLASSIFICATION COMPLAINT

COMPLAINT FOR WORKER MISCLASSIFICATION AS INDEPENDENT CONTRACTOR

PART 1: COMPLAINANT INFORMATION

Full Legal Name: _______________________________________________

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

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

Social Security Number (Last 4 digits): XXX-XX-________

PART 2: EMPLOYER/BUSINESS INFORMATION

Company/Business Name: _______________________________________________

Doing Business As (DBA): _______________________________________________

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

Business Phone: _________________________

Business Website: _________________________

Type of Business: _______________________________________________

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

Supervisor/Manager Who Directed Your Work: _______________________________________________

Estimated Number of Workers: _________________________

PART 3: WORKING RELATIONSHIP DETAILS

Start Date of Working Relationship: _________________________

End Date (if applicable): _________________________

How Were You Classified by the Business?
☐ Independent Contractor (1099)
☐ Freelancer
☐ Consultant
☐ Gig Worker
☐ Temporary Worker through staffing agency
☐ Other: _________________________

Tax Forms Received:
☐ Form 1099-NEC/1099-MISC
☐ Form W-2
☐ No tax forms received
☐ Both 1099 and W-2 at different times

Did You Sign an Independent Contractor Agreement?
☐ Yes (attach copy if available)
☐ No
☐ Don't remember

Job Title/Role: _______________________________________________

Description of Work Performed:
_______________________________________________
_______________________________________________
_______________________________________________

PART 4: ECONOMIC REALITIES TEST FACTORS

The following factors help determine whether you should be classified as an employee under federal law. Check all that apply to your situation:

FACTOR 1: Nature and Degree of Control

How much control did the business have over your work?

☐ Business set my work schedule
☐ Business required me to work specific hours
☐ Business supervised how I performed the work
☐ Business provided training on how to do the work
☐ Business required me to follow specific methods/procedures
☐ Business dictated the order/sequence of work
☐ Business required attendance at meetings
☐ Business required regular reports/check-ins
☐ Business evaluated my work performance
☐ Business prohibited me from working for competitors
☐ Business could change my assignments at will

Control Evidence Notes:
_______________________________________________
_______________________________________________

FACTOR 2: Opportunity for Profit or Loss

What was your ability to affect your own profit or loss?

☐ I was paid a fixed hourly rate set by the business
☐ I was paid a fixed salary or flat fee set by the business
☐ I could not negotiate my pay rate
☐ I had no investment in equipment/materials
☐ Business provided all tools and equipment
☐ I had no ability to expand or take on more clients
☐ I had no advertising or marketing expenses
☐ I could not hire my own helpers
☐ My income depended solely on hours worked

Profit/Loss Evidence Notes:
_______________________________________________
_______________________________________________

FACTOR 3: Investment in Equipment and Materials

Who provided the tools and equipment for your work?

☐ Business provided all tools and equipment
☐ Business provided computer/software
☐ Business provided vehicle
☐ Business provided uniform/work attire
☐ Business paid for supplies/materials
☐ I made no significant investment in my own equipment
☐ Any equipment I provided was minimal/inexpensive

List equipment/materials provided by business:
_______________________________________________

List equipment/materials you provided:
_______________________________________________

FACTOR 4: Skill and Initiative

What level of skill and independent business judgment was required?

☐ Work required no specialized skills
☐ Business trained me to perform the work
☐ I did not use any unique or special skills
☐ I did not exercise independent business judgment
☐ I followed instructions/guidelines from the business
☐ Work was routine/standardized

Skill/Initiative Evidence Notes:
_______________________________________________

FACTOR 5: Permanence of the Relationship

How permanent or indefinite was the working relationship?

☐ I worked for this business continuously
☐ I worked regular/consistent hours each week
☐ The relationship lasted more than one year
☐ There was an expectation of ongoing work
☐ I did not work on a project-by-project basis
☐ I did not have a fixed end date when starting
☐ I worked exclusively or primarily for this one business

Duration of relationship: __________ months/years

Permanence Evidence Notes:
_______________________________________________

FACTOR 6: Integration into Business Operations

How integrated was your work into the business's operations?

☐ My work was essential to the business's operations
☐ I performed the same work as employees
☐ I worked at the business's location
☐ I used business email address
☐ I appeared to be an employee to customers
☐ I was included in staff meetings
☐ I was listed on company website/directory
☐ My work was not a separate business or enterprise

Integration Evidence Notes:
_______________________________________________

PART 5: ABC TEST FACTORS (FOR APPLICABLE STATES)

Some states use the ABC Test, which presumes you are an employee unless ALL of the following are met. Indicate which conditions were NOT met:

A) Free from Control:
☐ I was NOT free from direction and control in performing the work

B) Outside Usual Course of Business:
☐ My work WAS within the usual course of the business's operations

C) Customarily Engaged in Independent Business:
☐ I was NOT engaged in an independently established trade, occupation, or business

PART 6: ADDITIONAL EVIDENCE OF EMPLOYEE STATUS

Working Conditions:

☐ I had a regular work schedule set by the business
☐ I reported to a specific location each day
☐ I was required to attend mandatory meetings
☐ I had to request time off/vacation
☐ I received performance reviews
☐ I was subject to disciplinary action
☐ I wore a uniform or badge identifying me with the business
☐ I had a business email address
☐ I appeared on the company organization chart
☐ I was included in company communications

Restrictions:

☐ I was prohibited from working for competitors
☐ I could not set my own rates
☐ I could not refuse assignments
☐ I could not hire my own assistants
☐ I was restricted in marketing my own services

Benefits Denied Due to Misclassification:

☐ Health insurance
☐ Retirement benefits/401(k)
☐ Paid time off/vacation
☐ Sick leave
☐ Workers' compensation coverage
☐ Unemployment insurance
☐ Social Security contributions (employer share)
☐ Medicare contributions (employer share)
☐ Overtime pay
☐ Minimum wage protections
☐ Other: _________________________

PART 7: DAMAGES CALCULATION

Wages Lost Due to Misclassification:

Unpaid Overtime:
| Period | Hours Over 40 | OT Rate | Amount Owed |
|--------|---------------|---------|-------------|
| _______ | _____________ | $______ | $___________ |
| _______ | _____________ | $______ | $___________ |
| _______ | _____________ | $______ | $___________ |

Subtotal Unpaid Overtime: $_________________________

Minimum Wage Differential (if applicable):
- Hours worked at below minimum wage: _________________________
- Amount per hour below minimum: $_________________________
- Subtotal Minimum Wage: $_________________________

Self-Employment Tax Burden (Employer's Share):
- Estimated employer FICA owed: $_________________________
(Employers pay 7.65% of wages for Social Security and Medicare; misclassified workers pay the full 15.3%)

Denied Benefits Value (estimated):
- Health insurance: $_________________________
- Retirement contributions: $_________________________
- Paid time off: $_________________________
- Other: $_________________________
- Subtotal Denied Benefits: $_________________________

Business Expenses Wrongly Incurred:
- Equipment/tools: $_________________________
- Vehicle/mileage: $_________________________
- Supplies: $_________________________
- Insurance: $_________________________
- Other: $_________________________
- Subtotal Business Expenses: $_________________________

TOTAL DAMAGES SUMMARY

PART 8: SUPPORTING DOCUMENTATION

Documents in Your Possession (check all that apply):

☐ Independent contractor agreement
☐ 1099 tax forms
☐ Payment records/invoices
☐ Work schedules (provided by business)
☐ Emails/communications showing control
☐ Training materials from business
☐ Company policies you were required to follow
☐ Performance reviews
☐ Photographs (uniform, badge, worksite)
☐ Business cards with company name
☐ Correspondence about work assignments
☐ Records of expenses incurred
☐ Other: _________________________

PART 9: OTHER AFFECTED WORKERS

Are other workers misclassified by this business?
☐ Yes ☐ No ☐ Unknown

If yes:
- Estimated number: _________________________
- Job titles/roles: _______________________________________________
- Would they participate in a complaint? ☐ Yes ☐ No ☐ Unknown

PART 10: PRIOR COMPLAINTS AND RETALIATION

Have you complained to the business about misclassification?
☐ Yes ☐ No

If yes:
- Date: _________________________
- Response: _______________________________________________

Have you experienced retaliation?
☐ Yes ☐ No

If yes, describe:
☐ Contract terminated
☐ Work assignments reduced
☐ Pay reduced
☐ Negative references
☐ Threats
☐ Other: _________________________

PART 11: STATE-SPECIFIC NOTES

CALIFORNIA

• ABC Test applies under AB 5 (Dynamex decision)
• AB 1514 (effective January 1, 2026) refines exemptions for certain professionals
• File with Labor Commissioner (DLSE) or Employment Development Department (EDD)
• Penalties include back taxes, unpaid wages, and penalties
• Private right of action under Labor Code
• Strong enforcement for gig economy workers

TEXAS

• Texas uses federal "economic realities" test
• Texas Workforce Commission handles unemployment tax issues
• File federal claims with DOL
• Penalties mainly federal under FLSA and IRS

FLORIDA

• Florida follows federal classification standards
• File with Florida Department of Revenue for tax issues
• DOL handles wage and hour complaints
• Reemployment Assistance (unemployment) claims with DEO

NEW YORK

• New York uses a strict control test
• Construction industry has specific presumption of employment
• File with NY Department of Labor
• Significant penalties under state law
• Criminal penalties available for willful misclassification

PART 12: FILING OPTIONS

Federal Agencies:

☐ U.S. Department of Labor, Wage and Hour Division
- For FLSA minimum wage and overtime claims
- Phone: 1-866-4-US-WAGE (1-866-487-9243)
- Website: www.dol.gov/agencies/whd/flsa/misclassification

☐ Internal Revenue Service (IRS)
- Form SS-8: Determination of Worker Status
- For federal tax purposes
- Website: www.irs.gov/forms-pubs/about-form-ss-8

☐ National Labor Relations Board (NLRB)
- If misclassification affects collective bargaining rights
- Website: www.nlrb.gov

State Agencies:

☐ State Labor Department
- State: _________________________
- Agency: _________________________

☐ State Tax/Revenue Agency
- For state employment tax issues

☐ State Unemployment Agency
- For unemployment insurance coverage

Private Legal Action:

☐ Private Lawsuit
- May recover wages, damages, attorney fees
- Consult with employment attorney

PART 13: DECLARATION

I declare under penalty of perjury that the information contained in this complaint is true and correct to the best of my knowledge and belief. I understand that providing false information may subject me to penalties.

I authorize the investigating agency to contact the business identified herein and to investigate this matter.

Complainant Signature: _______________________________________________

Printed Name: _______________________________________________

Date: _________________________

PART 14: ATTORNEY/REPRESENTATIVE INFORMATION

Are you represented?
☐ Yes ☐ No

Attorney/Representative Information:
- Name: _______________________________________________
- Firm/Organization: _______________________________________________
- Address: _______________________________________________
- Phone: _________________________
- Email: _________________________
- Bar Number: _________________________

MISCLASSIFICATION ANALYSIS SUMMARY

Based on the factors checked above, summarize why you believe you were misclassified:

Control Factors Supporting Employee Status:
_______________________________________________
_______________________________________________

Economic Reality Factors Supporting Employee Status:
_______________________________________________
_______________________________________________

ABC Test Factors NOT Met (if applicable):
_______________________________________________

Overall Conclusion:
_______________________________________________
_______________________________________________

CHECKLIST BEFORE FILING

☐ All sections completed
☐ Economic realities/ABC test factors analyzed
☐ Damages calculated
☐ Supporting documents gathered
☐ Copies made for records
☐ Appropriate agency identified
☐ Statute of limitations verified
☐ Considered legal consultation

RESOURCES

• DOL Misclassification Information: www.dol.gov/agencies/whd/flsa/misclassification
• IRS Form SS-8: www.irs.gov/forms-pubs/about-form-ss-8
• USA.gov Misclassification: www.usa.gov/job-misclassification
• Worker.gov: www.worker.gov

This template is provided for informational purposes only and does not constitute legal advice. Worker classification law is complex and varies by jurisdiction and applicable law (FLSA, tax, unemployment, workers' compensation). Consult with a qualified employment attorney for advice specific to your situation.