State Labor Board Wage Complaint

STATE LABOR BOARD WAGE COMPLAINT

COMPLAINT TO STATE DEPARTMENT OF LABOR / LABOR COMMISSIONER

IMPORTANT NOTICE

State labor laws and filing procedures vary significantly. This template provides a general framework that can be adapted for various state labor agencies. Always check your specific state's requirements, forms, and deadlines.

Common State Labor Agencies:

• California: Division of Labor Standards Enforcement (DLSE)
• New York: Department of Labor
• Texas: Texas Workforce Commission
• Illinois: Department of Labor
• Florida: No state enforcement (file with federal DOL)
• Pennsylvania: Department of Labor & Industry
• Ohio: Bureau of Wage and Hour Administration

PART 1: AGENCY INFORMATION

State: _______________________________________________

Agency Name: _______________________________________________

Agency Address:

• Street: _______________________________________________
• City: _________________________ State: _____ ZIP: ___________

Agency Phone: _________________________

Agency Website: _________________________

Claim/Case Number (if assigned): _________________________

PART 2: COMPLAINANT (EMPLOYEE) INFORMATION

Full Legal Name: _______________________________________________

Other Names Used: _______________________________________________

Date of Birth: _________________________

Social Security Number (Last 4 digits): XXX-XX-________
(Provide full SSN only if required by state agency)

Current Address:

• Street: _______________________________________________
• City: _________________________ State: _____ ZIP: ___________

Mailing Address (if different):

• Street: _______________________________________________
• City: _________________________ State: _____ ZIP: ___________

Contact Information:

• Home Phone: _________________________
• Cell Phone: _________________________
• Work Phone: _________________________
• Email: _________________________
• Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

Preferred Language: ☐ English ☐ Spanish ☐ Other: _______________

Need Interpreter: ☐ Yes ☐ No

Best Time to Contact: _________________________

PART 3: EMPLOYER INFORMATION

Employer Legal Name: _______________________________________________

Doing Business As (DBA): _______________________________________________

Employer Type:
☐ Corporation
☐ LLC
☐ Partnership
☐ Sole Proprietorship
☐ Government Entity
☐ Non-Profit
☐ Other: _________________________

Employer Address (Principal Place of Business):

• Street: _______________________________________________
• City: _________________________ State: _____ ZIP: ___________

Work Location (if different):

• Street: _______________________________________________
• City: _________________________ State: _____ ZIP: ___________

Employer Contact Information:

• Phone: _________________________
• Fax: _________________________
• Email: _________________________
• Website: _________________________

Employer Identification Number (EIN) (if known): _________________________

Owner/Principal Names:

1. _______________________________________________
2. _______________________________________________

Supervisor/Manager Name: _______________________________________________

HR Contact Name: _________________________

Payroll Contact Name: _________________________

Number of Employees (estimate): _________________________

Type of Business/Industry: _______________________________________________

PART 4: EMPLOYMENT INFORMATION

Job Title(s): _______________________________________________

Department: _______________________________________________

Employment Dates:

• Date of Hire: _________________________
• Date of Separation: _________________________ ☐ Still Employed

Reason for Separation (if applicable):
☐ Fired/Discharged
☐ Laid Off
☐ Resigned (voluntary)
☐ Constructive Discharge
☐ Contract Ended
☐ Still Employed
☐ Other: _________________________

Employment Type:
☐ Full-Time
☐ Part-Time
☐ Temporary
☐ Seasonal
☐ On-Call

Worker Classification:
☐ Employee (W-2)
☐ Independent Contractor (1099)
☐ Disputed/Uncertain

Union Member:
☐ Yes - Union Name: _________________________
☐ No

Collective Bargaining Agreement:
☐ Yes ☐ No

PART 5: WAGE AND PAYMENT INFORMATION

Agreed Pay Rate at Hire:
☐ Hourly: $__________ per hour
☐ Salary: $__________ per ☐ week ☐ bi-weekly ☐ month ☐ year
☐ Piece Rate: $__________ per __________
☐ Commission: __________% of __________
☐ Day Rate: $__________ per day
☐ Tips: $__________ average per __________

Pay Rate at Separation (if different): $__________ per __________

Pay Frequency:
☐ Weekly (every week)
☐ Bi-Weekly (every two weeks)
☐ Semi-Monthly (twice per month)
☐ Monthly
☐ Other: _________________________

Regular Payday: _________________________

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

Did You Receive:

• Pay stubs/wage statements: ☐ Yes ☐ No ☐ Sometimes
• Written wage notice at hire: ☐ Yes ☐ No
• Written notice of pay changes: ☐ Yes ☐ No

PART 6: WORK SCHEDULE INFORMATION

Typical Work Schedule:

Average Hours Per Week: _________________________

Did You Work Overtime (over 40 hours/week)?
☐ Yes - Average OT hours: __________ per week
☐ No

PART 7: TYPE OF VIOLATION (Check All That Apply)

Unpaid Wages

☐ Wages not paid at all
☐ Wages paid late
☐ Partial payment only
☐ Bounced/returned paycheck
☐ Last paycheck not received

Final Pay Violations

☐ Final paycheck not received after termination
☐ Final paycheck not received after resignation
☐ Final paycheck incomplete

Minimum Wage Violations

☐ Paid below state minimum wage ($__________)
☐ Paid below local minimum wage ($__________)
☐ Deductions reduced pay below minimum wage

Overtime Violations

☐ No overtime pay for hours over 40/week
☐ Incorrect overtime rate
☐ No daily overtime (CA only: over 8 hrs/day)
☐ No 7th day overtime (CA only)

Meal and Rest Break Violations (State-Specific)

☐ Meal breaks not provided
☐ Rest breaks not provided
☐ Meal/rest breaks interrupted
☐ No premium pay for missed breaks

Wage Deductions

☐ Unauthorized deductions
☐ Deductions for cash shortages
☐ Deductions for breakage/damage
☐ Deductions for uniforms
☐ Deductions for tools/equipment
☐ Other illegal deductions: _________________________

Tip Violations

☐ Tips taken by employer
☐ Tips taken by management
☐ Illegal tip pooling
☐ No tip credit notice

Pay Statement/Notice Violations

☐ No pay stubs provided
☐ Inaccurate pay stubs
☐ No wage notice at hire

Other Violations

☐ Unpaid vacation/PTO
☐ Unpaid sick leave
☐ Unpaid bonuses
☐ Unpaid commissions
☐ Unpaid expense reimbursements
☐ Split shift premium not paid
☐ Reporting time pay not provided
☐ Other: _________________________

Retaliation

☐ Retaliated against for wage complaint
☐ Terminated for complaining
☐ Hours/pay reduced for complaining

PART 8: DETAILED DESCRIPTION OF VIOLATION

Describe what happened in detail:
(Include dates, times, amounts, names of supervisors, specific incidents)

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

Period of Violation:

• Start Date: _________________________
• End Date: _________________________ ☐ Ongoing

PART 9: CALCULATION OF WAGES OWED

Complete all applicable sections:

A. Unpaid Regular Wages

Subtotal Unpaid Regular Wages: $_________________________

B. Unpaid Overtime

Subtotal Unpaid Overtime: $_________________________

C. Meal/Rest Break Premium Pay (CA and applicable states)

Subtotal Meal/Rest Break Premium: $_________________________

D. Other Amounts Owed

Subtotal Other Amounts: $_________________________

TOTAL WAGES CLAIMED

PART 10: SUPPORTING DOCUMENTATION

Attach copies of all documents you have (check all attached):

☐ Pay stubs/wage statements
☐ Time records/time cards
☐ Work schedules
☐ Employment contract/offer letter
☐ Employee handbook
☐ Company policies
☐ Personal log of hours worked
☐ Bank statements showing deposits
☐ Bounced checks
☐ Text messages regarding work/pay
☐ Emails regarding work/pay
☐ W-2 or 1099 tax forms
☐ Photographs (schedules, time clock, etc.)
☐ Witness information
☐ Prior complaint to employer
☐ Employer's response to complaint
☐ Other: _________________________

Note: Keep originals; submit copies only.

PART 11: PRIOR ATTEMPTS TO RESOLVE

Did you ask your employer to pay the wages owed?
☐ Yes ☐ No

If yes:

• Date(s): _________________________
• Who did you contact: _________________________
• How (verbal, written, email): _________________________
• Response received: _______________________________________________

Did you send a written demand letter?
☐ Yes ☐ No

If yes, attach a copy.

PART 12: OTHER CLAIMS AND PROCEEDINGS

Have you filed a claim regarding this matter with any other agency?
☐ Yes ☐ No

If yes:

• Agency: _________________________
• Date Filed: _________________________
• Claim Number: _________________________
• Status: _________________________

Have you filed a lawsuit regarding this matter?
☐ Yes ☐ No

If yes:

• Court: _________________________
• Case Number: _________________________
• Status: _________________________

Do you have an attorney?
☐ Yes ☐ No

If yes:

• Attorney Name: _________________________
• Phone: _________________________
• Email: _________________________

PART 13: OTHER AFFECTED EMPLOYEES

Are other employees affected by the same violation?
☐ Yes ☐ No ☐ Unknown

If yes:

• Estimated number: _________________________
• Job titles: _______________________________________________
• Would they be willing to participate: ☐ Yes ☐ No ☐ Unknown

PART 14: STATE-SPECIFIC INFORMATION

CALIFORNIA (DLSE)

Agency: Division of Labor Standards Enforcement (Labor Commissioner's Office)
Website: www.dir.ca.gov/dlse
Phone: 1-844-522-6734

California-Specific Violations:
☐ Daily overtime (over 8 hours/day)
☐ Double time (over 12 hours/day)
☐ 7th consecutive day overtime
☐ Meal period violations (30 min for 5+ hours)
☐ Rest period violations (10 min per 4 hours)
☐ Split shift premium
☐ Reporting time pay
☐ Waiting time penalties (final pay)
☐ Pay stub violations (Labor Code § 226)
☐ Wage notice violations (Labor Code § 2810.5)

Statute of Limitations:

• Most wage claims: 3 years
• Written contract claims: 4 years

NEW YORK (DOL)

Agency: New York State Department of Labor
Website: dol.ny.gov
Phone: 1-888-469-7365

Filing Methods:

• Online: dol.ny.gov/labor-standards-complaint-form
• By Mail: Division of Labor Standards, State Office Campus, Building 12, Albany, NY 12240

NY-Specific Information:

• 6-year statute of limitations for wage claims
• Liquidated damages of 100% available
• Spread of hours pay (over 10 hours)
• Call-in pay requirements

Form Required: LS223 (Labor Standards Complaint Form)

TEXAS (TWC)

Agency: Texas Workforce Commission
Website: www.twc.texas.gov
Phone: 1-800-832-9243

Texas Notes:

• Covers wage payment (Payday Law)
• Does NOT cover overtime (file with federal DOL)
• Does NOT cover minimum wage (file with federal DOL)
• Deadline: 180 days from date wages were due

Filing: Online at www.twc.texas.gov

FLORIDA

Important: Florida does not have a state agency that handles wage claims for most workers.

Options:

• File with U.S. Department of Labor for FLSA claims
• File lawsuit in court
• Some counties have local wage theft ordinances

ILLINOIS (IDOL)

Agency: Illinois Department of Labor
Website: labor.illinois.gov
Phone: 1-312-793-2800

Illinois-Specific:

• Covers minimum wage and overtime
• One Day Rest in Seven Act
• Prevailing Wage Act (public works)
• Deadline: 3 years for wage claims

PART 15: DECLARATION AND SIGNATURE

I, _________________________, declare under penalty of perjury under the laws of the State of _________________________ that:

1. The information in this complaint is true and correct to the best of my knowledge and belief.

2. I authorize the [State Agency Name] to investigate this complaint, contact my employer, and take appropriate enforcement action.

3. I understand that I may be contacted for additional information and may be required to participate in proceedings.

4. I understand that filing a false claim may subject me to penalties.

5. I understand that retaliation against me for filing this complaint is illegal.

Signature: _______________________________________________

Printed Name: _______________________________________________

Date: _________________________

PART 16: REPRESENTATIVE AUTHORIZATION (IF APPLICABLE)

Are you represented by an attorney or authorized representative?
☐ Yes ☐ No

If yes:

Representative Name: _______________________________________________

Organization/Firm: _______________________________________________

Address: _______________________________________________

Phone: _________________________ Email: _________________________

Bar Number (if attorney): _________________________

I authorize the above-named representative to act on my behalf:

Claimant Signature: _______________________________________________

Date: _________________________

CHECKLIST BEFORE FILING

☐ Correct state agency identified
☐ All sections completed
☐ Wages owed calculated accurately
☐ Supporting documents copied and attached
☐ Kept originals for your records
☐ Statute of limitations verified
☐ Form signed and dated
☐ Representative authorization signed (if applicable)

WHAT HAPPENS AFTER FILING

1. Acknowledgment: Agency confirms receipt of complaint
2. Assignment: Case assigned to investigator/hearing officer
3. Investigation: Agency may contact both parties
4. Conference: Settlement conference may be scheduled
5. Hearing: If unresolved, formal hearing may occur
6. Decision: Agency issues decision/award
7. Collection: If you win, agency may assist with collection

STATE LABOR AGENCY CONTACTS

This template is provided for informational purposes only and does not constitute legal advice. State labor laws and procedures vary significantly. Always verify current requirements with your state agency or consult with a qualified employment attorney.