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Compliance Tracking System (CTS)
    

Act 75 Complaint
Department of Labor & Industry - Bureau of Labor Law Compliance - Construction Industry Employee Verification Act complaint form
This form is used for complaints under the Pennsylvania Act 75
*The Department may not investigate a claim based on race, color, or national origin*
An individual who knowingly provides materially false information on this complaint form shall be subject to punishment under 18 PA.C.S. § 4904
Claimant Information
First Name: * Daytime Telephone:
Initial: Evening Telephone:
Last Name: * Fax:
Address - Line 1: * E-Mail: *
Address - Line 2:
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: *
Additional Business Information
What type of construction service does the business perform? *
Owner of the business: *
Employment Information
Provide the following information about each worker that you believe has not been verified by the construction employer:

First Name Last Name Type of Work Performed Work Site Name Work Location
1.
2.
3.
4.
5.
6.
7.
8.
Why do you contend that the construction company did not verify employees prior to hiring the named individuals:
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).