Labor Commissioner, State of California Department of Industrial Relations Division of Labor Standards Enforcement TAKEN BY: DATE TAKEN: OFFICE: DIVISION USE ONLY: CASE # ASSIGNED TO: DATE RECEIVED: DATE ASSIGNED: PUBLIC WORKS ­ WORKER COMPLAINT The following information is important and must be provided. Complainant/Worker Information 1. FIRST NAME 5. CONTACT ADDRESS 2. LAST NAME 3. HOME TEL. NO. 6. CITY 4. WORK/CELLULAR NO 7. STATE/ ZIP CODE 8. EMAIL ADDRESS Project Information Note: A separate form must be completed for each project in which you are alleging a violation of prevailing wages. 9. PROJECT NAME (If known) 10. LIST THE ADDRESSES OF THE PROJECT WHERE YOU PERFORMED WORK: 11. NAME OF BUSINESS/CONTRACTOR/EMPLOYER Complaint Against 12. CONTRACTOR'S STATE LIC. NO 13. ADDRESS 14. BUSINESS TEL. NO 15. NAME OF PERSON IN CHARGE/ TITLE 16. EMAIL ADDRES 17. ARE YOU STILL WORKING FOR THIS CONTRACTOR? Awarding Body 18. NAME OF PUBLIC AGENCY/AWARDED CONTRACT ENTITY 19. ADDRESS 20. BUSINESS TEL. NO 21. NAME OF PERSON IN CHARGE/ TITLE 22. EMAIL ADDRESS 23. DATE PROJECT BEGAN 24. ESTIMATED COMPLETION DATE 25. DATE OF NOTICE OF COMPLETION General Contractor (Prime Contractor) 26. NAME OF GENERAL CONTRACTOR 27. CONTRACTOR'S STATE LIC. 28. ADDRESS 29. BUSINESS TEL. NO 30. NAME OF PERSON IN CHARGE/ TITLE 31. EMAIL ADDRESS Issues 32. BRIEF EXPLAINATION OF ISSUES: (Check all applicable boxes) Non-payment /Underpayment of wages Unpaid overtime/Sat/Sun/Holiday rate Fringe benefits not paid Not paid travel and subsistence Misclassification of worker Other Under reporting of hours Insufficient fund check DLSE-PW 1 (Revised Sept/2012) (Continued on next page) American LegalNet, Inc. www.FormsWorkFlow.com Employment Information 33. WHAT WAS YOUR JOB TITLE? 34. DESCRIBE YOUR JOB DUTIES? 35. WHAT TOOLS DID YOU USE TO PERFORM YOUR JOB DUTIES? 36. HOW WERE YOU PAID? 37. WERE YOU GIVEN A CHECK STUB? 38. HOW OFTEN WERE YOU PAID? 39. HOW MUCH WERE YOU PAID? $ ______________________ 40. WERE YOU PAID: (Please check all applicable boxes) Overtime Rate Double Time Rate No ___ Yes ___ $ _______ ________ No ___ Yes ___ $________ _______ Yes Saturday Rate No ___ Yes ___ $_______ ___________ Check Yes Daily Per Hour Cash No Weekly Bi-weekly Per Day Monthly Semi-Monthly Per Week Other Direct Deposit Other Sun/Holiday Rate No ___ Yes ___ $________ _________ 41. DID YOUR EMPLOYER KEEP TIME AND PAYROLL RECORDS? 42. WHO WAS IN POSSESSION OF THESE RECORDS? No Do Not Know 43. DID YOU KEEP AN ACCURATE RECORD OF YOUR HOURS WORKED? Yes 44. DATES YOU WORKED ON THIS PROJECT: 45. DID YOU WORK ON ANOTHER PROJECT AT THE SAME TIME YOU WORKED ON THIS PROJECT? 46. IF YES, FOR WHO? WHERE? WHEN? Yes No HOURS No 47. DID YOU RECEIVE TRAVEL AND SUBSISTENCE PAYMENT? 48. LIST CO-WORKERS/WITNESS INFORMATION: NO YES, IF YES, HOW MUCH? $___________________ Estimated number of workers who you are working with in this project: ___________________________________________________________ Please provide names, addresses, telephone numbers, and type of work of other workers? Please list their names below. Use additional sheets as necessary. Name of Worker 1) 2) 3) Address Telephone No. Types of Work Performed I hereby certify that this is a true statement to the best of my knowledge and belief. MY NAME MAY BE USED IN THIS INVESTIGATION. Yes No ____________________________________ Signature DLSE-PW 1 (Revised Sept/2012) ____________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com