FOR OFFICE USE ONLY Direct any correspondence to LABOR COMMISSIONER, STATE OF CALIFORNIA TAKEN BY DATE OFFICE VIOLATION OF SECTION NAME OF CODE ASSIGNED INVESTIGATOR RETALIATION COMPLAINT CASE NUMBER PLEASE PRINT ALL INFORMATION NAME HOME TELEPHONE NO. CURRENT WORK PHONE NO. YOUR ADDRESS-NUMBER AND STREET, APARTMENT OR SPACE NUMBER, CITY, ZIP CODE SEX SOCIAL SECURITY NAME OF BUSINESS CALIFORNIA DRIVER LICENSE NO. DATE OF BIRTH F CORPORATION F PARTNERSHIP F SOLE OWNER EMPLOYER’S NAME ADDRESS OF BUSINESS-NUMBER AND STREET, CITY, ZIP CODE TELEPHONE NUMBER ADDRESS WHERE YOU WORKED IF DIFFERENT THAN ABOVE DATE OF HIRE? YOUR DEPARTMENT AND JOB TITLE RATE OF PAY NUMBER OF HOURS WORKED? NAME OF SUPERVISOR TYPE OF BUSINESS PER WEEK PER DAY ESTIMATED NO. EMPLOYEES WAS YOUR JOB UNION? IF YES, NAME AND ADDRESS OF UNION? TELEPHONE BY WHOM? NAME AND TITLE ARE YOU STILL WORKING FOR THIS EMPLOYER? WERE YOU DISCHARGED? IF YES-DATE F YES F NO DID YOU NOTIFY YOUR EMPLOYER OF INTENTION TO FILE A CLAIM WITH THE LABOR COMMISSIONER? DID YOU FILE A SAFETY COMPLAINT? F YES F NO DID YOU NOTIFY OSHA? F YES IF YES-DATE IF YES-DATE IF YES-DATE F YES F NO NAME AND TITLE OF PERSON NOTIFIED? F NO WITH WHOM-NAME AND ADDRESS? WHICH OFFICE? F YES F NO NAME AND TITLE OF PERSON(S) YOU BELIEVE RETALIATED AGAINST YOU? WHAT REMEDY ARE YOU SEEKING THROUGH THIS DIVISION? F YES HAVE YOU FILED WITH ANY OTHER GROUP OR AGENCY? F NO IF YES, WHICH OFFICE? ___________________________________________________________________________________________________________________________________ ADDRESS TELEPHONE NAME ARE YOU BEING REPRESENTED BY AN ATTORNEY? F YES F NO ____________________________________________________________________________________________________________________________________ ADDRESS TELEPHONE NAME INTERPRETER NEEDED? F YES F NO IF INTERPRETER NEEDED, WHAT LANGUAGE? LIST NAME, JOB TITLES AND TELEPHONE NUMBER (IF POSSIBLE) OF WITNESSES, CO-WORKERS OR THOSE YOU FEEL COULD PROVIDE EVIDENCE IN YOUR SUPPORT TO THE ACTS YOU ARE COMPLAINING ABOUT. USE ADDITIONAL SHEETS DLSE 205 (REV. 11/2010) RETALIATION COMPLAINT/ENGLISH 1 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF CALIFORNIA DEPARTMENT OF INDUSTRIAL RELATIONS DIVISION OF LABOR STANDARDS ENFORCEMENT Give a written statement answering each of the questions in the space provided below. After answering these questions, if you wish, you may also attach additional sheets to provide a more detailed description of the circumstances of the retaliatory act. 1. Protected activity (What did you do that caused your employer to retaliate against you?) Date of protected activity: 2. Employer knowledge (How did your employer know you engaged in a protected activity?) Date of employer knowledge: 3. Adverse action (What did your employer do to you because you engaged in a protected activity?) Date of adverse action: I certify under penalty of perjury, under the laws of the State of California, that the foregoing is true and correct EXECUTED ON, , AT CALIFORNIA SIGNATURE IF ADDITIONAL PAGES ARE USED, YOU MUST INITIAL, DATE AND NUMBER EACH PAGE. DLSE 205 (REV. 11/2010) RETALIATION COMPLAINT/ENGLISH 2 American LegalNet, Inc. www.FormsWorkFlow.com