Compliance Tracking System (CTS)

Wage Complaint
Department of Labor & Industry - Bureau of Labor Law Compliance - Wage Payment Complaint
This form is used for complaints under the Pennsylvania Minimum Wage Act of 1968 and the Wage Payment and Collection Law.
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 of where your work took place: *
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 of employment between you and the named employer?: *
2. What was your regular payday to be?: *
If Other, please explain: *
3. Were wages paid to you in a form other than a check?: *
If Yes, please explain: *
4. What was the latest rate of pay agreed upon between you and the named employer?:
Hourly $: *
Weekly $: *
Other (please explain): *
5. How much money do you claim you are owed in this matter?: *
6. 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.
7. State employer's reason for refusal of payment: *
8. Have any deductions been made without your written agreement?: *
If Yes, please explain: *
9. Do you owe any money to the named employer for any reason?: *
If Yes, how much? $: *
10. 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 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.