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Compliance Tracking System (CTS)
    

Prevailing Wage Complaint
Department of Labor & Industry - Bureau of Labor Law Compliance - Prevailing Wage Complaint
This form is used for complaints under the Pennsylvania Prevailing Wage Act of 1961.
Claimant Information
First Name: * Area Code - Daytime Telephone: *
Initial: Area Code - 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: State: *
Last Name of Owner: City: *
Zip: *
County:
Project Details
Project Name: *
County: *
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. Was there a written contract between you and the named employer?: *
2. Were you notified by the named employer as to when and where you would be paid?: *
3. What was your regular payday to be?: *
If Other, please explain: *
4. Were wages paid to you in a form other than a check?:
If Yes, please explain:
5. What was the latest rate of pay agreed upon between you and the named employer?:
Enter hourly rate $: *
6. What are the TOTAL wages claimed by you? $: *
7. Please enter the following information regarding the wages you are claiming: (week ending date, number of hours worked, rate of pay per hour, day, week or other, total gross wages earned, and specify if vacation pay, sick leave or commission).
NOTE: Failure to provide detailed information in the space provided above may make it impossible to pursue this claim on your behalf.
8. Did the named employer refuse to pay these wages? *
If Yes, state employer's reason for refusal: *
9. Do you and the named employer agree as to the amount of wages due to you?: *
If No, what amount does the named employer acknowledge as being due? $: *
10. Has the named employer given you written confirmation of the amount due to you?: *
11. Has the named employer offered to pay you the amount to be due?: *
If Yes, have you accepted the amount offered?: *
12. Have you agreed in writing to any deductions?: *
If Yes, please list deductions: *
13. Have any deductions been made without your written agreement?: *
If Yes, please explain: *
14. Do you owe any money to the named employer for any reason?: *
If Yes, how much? $: *
15. Are you covered under a Collective Bargaining Agreement?: *
If Yes, list the name and address of the union:
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 prevailing wages.
The Bureau will contact you for any further information.