BUREAU OF LABOR LAW COMPLIANCE
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:
*
---Select---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
*
---Select---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
*
County:
*
---Select---
None
Adams
Allegheny
Armstrong
Beaver
Bedford
Berks
Blair
Bradford
Bucks
Butler
Cambria
Cameron
Carbon
Centre
Chester
Clarion
Clearfield
Clinton
Columbia
Crawford
Cumberland
Dauphin
Delaware
Elk
Erie
Fayette
Forest
Franklin
Fulton
Greene
Huntingdon
Indiana
Jefferson
Juniata
Lackawanna
Lancaster
Lawrence
Lebanon
Lehigh
Luzerne
Lycoming
McKean
Mercer
Mifflin
Monroe
Montgomery
Montour
Northampton
Northumberland
Perry
Philadelphia
Pike
Potter
Schuylkill
Snyder
Somerset
Sullivan
Susquehanna
Tioga
Union
Venango
Warren
Washington
Wayne
Westmoreland
Wyoming
York
Out of State
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).
BUREAU OF LABOR LAW COMPLIANCE
651 BOAS STREET, ROOM 1301
HARRISBURG PA 17121
Phone: (800) 932-0665 Fax: (717) 787-0517
EMAIL: RA-LI-SLMR-LLC@pa.gov