Compliance Tracking System (CTS)

LAW Minimum Wage or Overtime
Department of Labor & Industry - Bureau of Labor Law Compliance -Minimum Wage and Overtime Complaint
This form is used for complaints under the Pennsylvania Minimum Wage Act of 1968.
Claimant Information
First Name: * Area - Daytime Telephone: *
Initial: Area - Evening Telephone:
Last Name: * Fax:
Address - Line 1: * E-Mail:
Address - Line 2:
City: *
State: *
Zip: *
Employer Information
First Name of Contact Person: * Company Name: *
Initial: Area - Daytime Telephone: *
Last Name of Contact Person: * Address - Line 1: *
First Name of Owner: * Address - Line 2:
Initial: City: *
Last Name of Owner: * State: *
Zip: *
Additional Employer Information
Location: *
Type of Work Performed: *
Complaint Details
Date Hired: (mm/dd/yyyy) *
Are you still employed by the named employer?: *
If No, give last date worked:(mm/dd/yyyy) *
Was your termination:
1. What was your regular payday?: *
If Other, please explain: *
2. What was the your rate of pay?:
Hourly $: *
Weekly $: *
Other (please explain): *
3. How often do you work over 40 hours per week?: *
4. Do you have Statement of Earnings(Pay Stubs) showing hours of work, rate of pay, etc.?: *
5. Did you retain your own record of hours worked?: *
You may enter additional information here to summarize related information and wage computations.
I hereby certify that to the best of my knowledge and belief, this is a true statement of facts relating to the above claim of unpaid wages.
I hereby assign the said wages and all penalty wages accruing because of nonpayment thereof, also all liens securing said wages to the Secretary of Labor and Industry of the Commonwealth of Pennsylvania, and any Deputy or Representative authorized to act on the Secretary's behalf, to collect under the provisions of Section 9.1(e) of the Wage Payment and Collection Law or Section 13 of the Pennsylvania Minimum Wage Act, Sec. 333.113.
Once we receive your Wage Complaint Form, we will log it in and assign it to a Labor Investigator and a confirmation letter will be sent out. The Bureau will contact you for any further information.