Compliance Tracking System (CTS)

Act 72 Complaint
Department of Labor & Industry - Bureau of Labor Law Compliance -Construction Workplace Misclassification Complaint
This form is used for complaints under the Pennsylvania Act 72
Claimant Information
First Name: * Daytime Telephone:
Initial: Evening Telephone:
Last Name: * Fax:
Address - Line 1: * E-Mail:
Address - Line 2: Occupation and job title:
City: *
State: *
Zip: *

Business Information
First Name of Contact Person: * Company Name: *
Initial: Telephone:
Last Name of Contact Person: * Address - Line 1: *
First Name of Owner: * Address - Line 2:
Initial: City: *
Last Name of Owner: * State: *
Zip: *
County: *
Establishment Code:

Additional Business Information
What type of construction service does the business perform? *
Owner of the business: *
Employment Information
For any of the questions below, you may add additional information on separate pages and include any documents that you feel are helpful:
Provide the following information (Name, Type of work performed and worksite name and location) about each worker that you believe the business misclassified, including yourself if applicable: *
Provide the following information (worksite name and location, project, dates when work was performed, worksite supervisor, name of general contractor) about worksite where you believe the business misclassified workers: *
What led you believe that this business misclassified employees as independent contractors? *
Did the business have any other person who provided the workers directions or orders besides the workspace supervisor(s)? *
If so, please identify the(se) person(s) and worksite(s): *
Did the business supply the workers with tools, equipment and other supplies to do their work? *
If yes, what tools, equipment and supplies were provided by the business: *
What tools, if any, did the worker(s) supply? *
Did any of the workers have their own business? *
If yes, please explain and provide the business location *
Did any of the workers have their own liability insurance? *
If yes, when was it in effect? (Please provide a copy of the declaration page, if available) *
How were the workers paid? (Please check all that apply and explain in detail)
Per job:
Per hour:
Per day:
Piece work:
Explain in detail: *
Who paid the workers? *
Do you have wage records (such as paystubs, W-2 or 1099 forms) relating to any of the workers? *
Did any of the workers have a written agreement to perform work at any of the worksites? *
If yes, please attach the documents below (You can attach upto three documents):
Upload PDF or JPEG files only
I verify that facts set forth in this complaint are true and correct to the best of my knowledge, information and belief, I sign this complaint subject to 18 Pa.C.S. 4904(relating to unsworn falsifications to authorities)