Complaint Details
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Date Hired: (mm/dd/yyyy)
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*
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Are you still employed by the named employer?:
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*
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If No, give last date worked:(mm/dd/yyyy)
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*
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Was your termination:
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1. What was your regular payday?:
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*
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If Other, please explain:
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*
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2. What was the your rate of pay?:
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Hourly $:
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*
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Weekly $:
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*
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Other (please explain):
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*
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3. How often do you work over 40 hours per week?:
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*
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4. Do you have Statement of Earnings(Pay Stubs) showing hours of work, rate of pay, etc.?:
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*
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5. Did you retain your own record of hours worked?:
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*
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You may enter additional information here to summarize related information and wage computations.
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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.
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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.
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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.
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