STATE WHISTLEBLOWER COMPLAINT

Multi-State Template with State-Specific Guidance

SELECT YOUR STATE

Check the state where you are filing:

☐ California
☐ New York
☐ Texas
☐ Florida
☐ Other State: _________________________________

Applicable Statute:

PART I: COMPLAINANT INFORMATION

A. Personal Information

Full Legal Name: _________________________________

Also Known As: _________________________________

Current Address:

Street: _________________________________

City: _________________ State: _______ ZIP: _________

Mailing Address (if different):

_____________________________________________________________________________

Contact Information:

Home Phone: _________________________________

Cell Phone: _________________________________

Personal Email: _________________________________

Preferred Contact Method: ☐ Phone ☐ Email ☐ Mail

Best Times to Reach You: _________________________________

B. Employment Information

Current Employment Status:
☐ Currently employed
☐ Terminated - Date: _________________________________
☐ Resigned - Date: _________________________________
☐ On leave - Type: _________________________________
☐ Other: _________________________________

Employer Name: _________________________________

Position/Title: _________________________________

Department: _________________________________

Work Location:

_____________________________________________________________________________

Date of Hire: _________________________________

Salary/Wage: $_________________ per _________________

PART II: EMPLOYER INFORMATION

A. Employer Details

Company/Agency Name: _________________________________

Type of Employer:
☐ Private Company
☐ State Government Agency
☐ Local Government Agency
☐ Non-Profit Organization
☐ Other: _________________________________

Address:

Street: _________________________________

City: _________________ State: _______ ZIP: _________

Phone: _________________________________

Number of Employees:
☐ Under 10
☐ 10-50
☐ 51-100
☐ 101-500
☐ Over 500

B. Management Contacts

Your Supervisor:

Name: _________________________________

Title: _________________________________

Human Resources Contact:

Name: _________________________________

Title: _________________________________

Person Who Retaliated:

Name: _________________________________

Title: _________________________________

PART III: PROTECTED ACTIVITY

A. Type of Protected Disclosure

What did you report or refuse to participate in?

☐ Violation of state law
☐ Violation of federal law
☐ Violation of local ordinance
☐ Violation of administrative rule or regulation
☐ Danger to public health
☐ Danger to public safety
☐ Gross mismanagement
☐ Gross waste of public funds
☐ Abuse of authority
☐ Other: _________________________________

B. Description of the Violation/Concern

Describe in detail the violation or concern you reported:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

C. To Whom Did You Report?

Internal Reporting:

☐ Supervisor - Name: _________________________________
☐ Human Resources - Name: _________________________________
☐ Compliance/Ethics - Name: _________________________________
☐ Executive/Management - Name: _________________________________
☐ Other Internal: _________________________________

External Reporting:

☐ State Government Agency - Name: _________________________________
☐ Federal Government Agency - Name: _________________________________
☐ Local Government Agency - Name: _________________________________
☐ Law Enforcement - Name: _________________________________
☐ Other External: _________________________________

D. When and How Did You Report?

Date(s) of Report: _________________________________

Method of Report:
☐ Written (letter, email, memo)
☐ Verbal (in person, phone)
☐ Hotline
☐ Online submission
☐ Other: _________________________________

Response Received:

_____________________________________________________________________________

PART IV: ADVERSE EMPLOYMENT ACTION

A. Type of Retaliation

Check all adverse actions taken against you:

☐ Termination/Discharge
☐ Demotion
☐ Suspension
☐ Reduction in pay
☐ Reduction in hours
☐ Denial of promotion
☐ Negative performance review
☐ Transfer/reassignment
☐ Harassment
☐ Threats
☐ Hostile work environment
☐ Denial of benefits
☐ Blacklisting
☐ Other: _________________________________

B. Details of Retaliation

Date of Adverse Action: _________________________________

Who Took the Adverse Action:

Name: _________________________________

Title: _________________________________

Describe what happened:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

C. Employer's Stated Reason

What reason did your employer give for the adverse action?

_____________________________________________________________________________

Why is this reason false or pretextual?

_____________________________________________________________________________

_____________________________________________________________________________

PART V: CAUSAL CONNECTION

A. Timing

Date of Protected Activity: _________________________________

Date of Adverse Action: _________________________________

Time Between: _________________________________

B. Evidence of Causation

☐ Close timing between protected activity and retaliation
☐ Decision-maker knew of protected activity
☐ Direct statements about my complaint
☐ Departure from company policy
☐ Disparate treatment compared to others
☐ Prior positive performance
☐ Other: _________________________________

Explain the connection between your protected activity and the retaliation:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

PART VI: DAMAGES

A. Economic Damages

Lost wages: $__________________

Lost benefits: $__________________

Job search costs: $__________________

Other economic losses: $__________________

Total Economic Damages: $__________________

B. Non-Economic Damages

☐ Emotional distress
☐ Anxiety/Depression
☐ Damage to reputation
☐ Humiliation
☐ Physical symptoms
☐ Other: _________________________________

PART VII: WITNESSES AND EVIDENCE

A. Witnesses

B. Documentary Evidence

PART VIII: PRIOR COMPLAINTS

Have you filed any other complaints about this matter?
☐ No
☐ Yes

If yes:

Agency/Court: _________________________________

Date Filed: _________________________________

Case Number: _________________________________

Status: _________________________________

STATE-SPECIFIC SECTIONS

CALIFORNIA - Labor Code § 1102.5

Statutory Coverage

California Labor Code § 1102.5 prohibits employer retaliation against employees who:

• Disclose information to a government or law enforcement agency about a reasonably believed violation of state or federal law
• Disclose information internally to a person with authority over the employee
• Provide information to or testify before a public body conducting an investigation
• Refuse to participate in an activity that would result in a violation of law

California-Specific Information

Were you employed in California?
☐ Yes ☐ No

Did you report to any of the following?
☐ California Labor Commissioner
☐ California Attorney General
☐ Cal/OSHA
☐ Other California agency: _________________________________

Did you report internally first?
☐ Yes ☐ No

Note: Internal reporting is NOT required under California law.

Filing Options in California

☐ Labor Commissioner Complaint - File with Division of Labor Standards Enforcement
☐ Civil Lawsuit - File in Superior Court
☐ Both - May pursue administrative and judicial remedies

Statute of Limitations: 3 years from the retaliatory act

Available Remedies:
- Reinstatement
- Back pay and lost wages
- Interest on back pay
- Reasonable attorney's fees
- Injunctive relief

2025 California Update

As of January 1, 2025, California employers must post a notice informing employees of their whistleblower rights. The notice must include the State's whistleblower hotline number: 1-800-952-5225.

California Labor Commissioner Contact:
Phone: (844) 522-6734
Website: www.dir.ca.gov/dlse

NEW YORK - Labor Law § 740

Statutory Coverage

New York Labor Law § 740 (as amended in 2022) prohibits retaliation against employees who:

• Disclose or threaten to disclose an activity, policy, or practice that violates any law, rule, or regulation
• Disclose an activity that creates a substantial and specific danger to public health or safety
• Object to or refuse to participate in any such activity
• Provide information to or testify before any public body conducting an investigation

New York-Specific Information

Type of Employer:
☐ Private employer
☐ Public employer (Note: NY Civil Service Law § 75-b may also apply)

Did you report internally first?
☐ Yes ☐ No

Note: Under the amended law, internal reporting is NOT required unless the employee reasonably believes that the violation poses an imminent threat or that internal reporting would be futile.

Category of Violation Reported:
☐ Violation of law, rule, or regulation
☐ Danger to public health or safety

Filing Options in New York

☐ Civil Lawsuit - File in State Supreme Court

Statute of Limitations: 2 years from the retaliatory act

Available Remedies (expanded in 2022):
- Injunctive relief
- Reinstatement with same seniority status
- Back pay with interest
- Front pay
- Compensation for special damages (litigation costs, attorney's fees, expert witness fees)
- Civil penalty up to $10,000
- Punitive damages (if employer acted willfully, maliciously, or wantonly)

New York Employer Posting Requirement

Employers must post a notice informing employees of their rights under Labor Law § 740.

New York Department of Labor Contact:
Phone: (518) 457-9000
Website: www.dol.ny.gov

TEXAS - Government Code Chapter 554

Statutory Coverage

IMPORTANT: The Texas Whistleblower Act ONLY protects public employees.

The Texas Whistleblower Act (Gov. Code Ch. 554) protects state and local government employees who report, in good faith, violations of law to an appropriate law enforcement authority.

Texas-Specific Information

Are you a public employee?
☐ Yes - Proceed with this section
☐ No - Texas Whistleblower Act does NOT apply. Consider federal protections only.

Type of Public Employer:
☐ State agency
☐ County
☐ City/Municipality
☐ School district
☐ Special district
☐ Other public entity: _________________________________

Did you report to an "appropriate law enforcement authority"?
☐ Yes - Agency: _________________________________
☐ No

Note: Reporting to the wrong authority may defeat your claim. "Appropriate law enforcement authority" means an entity authorized to investigate or prosecute violations of law.

Texas Filing Requirements

IMPORTANT PROCEDURAL REQUIREMENTS:

1. Initiate Grievance Procedure: Before filing suit, you must initiate action under your employer's grievance or appeal procedures within 90 days of learning of the retaliatory action.

2. File Lawsuit: If the grievance is not resolved within 60 days, you may file suit.

Statute of Limitations: 90 days to initiate grievance; suit must be filed within 90 days after completing grievance

Available Remedies in Texas

• Injunctive relief
• Reinstatement
• Compensation for lost wages
• Reasonable attorney's fees
• Court costs

Note: Punitive damages are NOT available under Texas law (capped since 1995).

Texas Attorney General's Office:
Phone: (800) 252-8011
Website: www.texasattorneygeneral.gov

FLORIDA - Statutes § 448.102 and § 112.3187

Private Sector - Fla. Stat. § 448.102

Coverage: Private employers with 10 or more employees

Protected Activity: Disclosing or objecting to violations of laws, rules, or regulations; participating in investigations

Note: As of July 1, 2025, Florida expanded protections for private sector workers.

Public Sector - Fla. Stat. § 112.3187

Coverage: Executive branch state agency employees

Protected Activity: Reporting violations of law creating substantial danger to public health, safety, or welfare; disclosing improper use of governmental office; disclosing gross waste of funds or abuse of authority

Florida-Specific Information

Type of Employer:
☐ Private employer with 10+ employees
☐ Private employer with fewer than 10 employees (limited protection)
☐ State government agency
☐ Local government agency

For Public Employees:
☐ I filed a complaint with the Florida Commission on Human Relations

For Private Employees:
☐ I am filing a civil lawsuit

Florida Filing Requirements

Private Sector:
- File civil lawsuit in state court
- Statute of Limitations: Varies (consult attorney)

Public Sector:
- File with Florida Commission on Human Relations within 60 days
- May then file civil lawsuit

Available Remedies in Florida

Private Sector (§ 448.102):
- Reinstatement
- Back pay
- Reasonable attorney's fees (but note: if you lose, you may owe employer's fees)

Note: Punitive damages are NOT available.

Public Sector (§ 112.3187):
- Reinstatement
- Back pay
- Reasonable attorney's fees
- Compensatory damages

Florida Commission on Human Relations:
Phone: (850) 488-7082
Website: fchr.myflorida.com

PART IX: CERTIFICATION AND SIGNATURE

I, _________________________, certify under penalty of perjury that:

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

2. I believe in good faith that the conduct I reported violated the law.

3. I understand the filing requirements and deadlines applicable to my state.

4. I agree to cooperate with any investigation of this complaint.

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

FILING INSTRUCTIONS BY STATE

California

Labor Commissioner:
Division of Labor Standards Enforcement
www.dir.ca.gov/dlse

Or file civil lawsuit in Superior Court

New York

File civil lawsuit in State Supreme Court

For guidance:
New York Department of Labor
www.dol.ny.gov

Texas

For public employees:
1. File grievance with employer within 90 days
2. If unresolved after 60 days, file lawsuit

Texas Workforce Commission:
www.twc.texas.gov

Florida

Private Sector:
File civil lawsuit in state court

Public Sector:
Florida Commission on Human Relations
fchr.myflorida.com

COMPARISON OF STATE LAWS

* Some exceptions apply
* For willful, malicious, or wanton violations
** If employee loses, may owe employer's fees (Florida private sector)

ATTACHMENTS CHECKLIST

☐ Completed complaint form
☐ Documents evidencing protected activity
☐ Documents evidencing retaliation
☐ Performance reviews
☐ Pay stubs/compensation records
☐ Employment contract (if any)
☐ Witness contact information
☐ Timeline of events

This template is provided for educational purposes only and does not constitute legal advice. State whistleblower laws vary significantly. The information provided is general in nature and may not reflect recent legislative changes. Consult an attorney licensed in your state before filing a complaint.