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  Initial      Last Name
Address - Line 1    Address - Line 2   City  State  Zip Code	() Area    Daytime Telephone     () Area   Evening Telephone    () Area   Fax    E-Mail

Employer Information   First Name of Contact Person   Initial       Last Name of Contact Person First Name of Owner   Initial       Last Name of Owner
Company Name     Address - Line 1    Address - Line 2   City  State  Zip Code	() Area     Telephone       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 Franklin Forest Fulton Greene Huntingdon Indiana Jefferson Juniata Lackawanna Lancaster Lawrence Lebanon Lehigh Luzerne Lycoming McKean Mercer Mifflin Monroe Montour Montgomery Northampton Northumberland Perry Philadelphia Pike Potter Schuylkill Snyder Somerset Sullivan Susquehanna Tioga Union Venango Warren Washington Wayne Westmoreland Wyoming York County

Additional Employer Information
	Location
	Type of Work Performed

Complaint Details
	Date Hired: (mm/dd/yyyy)
	Are you still employed by the named employer?			YesNo
	If No, give last date worked:(mm/dd/yyyy)
	Was your termination:	VoluntaryInvoluntary

	1.	Was there a written contract of employment between you and the named employer?								YesNo
	2.	What was your regular payday to be?   WeeklyBi-WeeklyMonthlyOther
		If Other, please explain:
	3.	Were wages paid to you in a form other than a check?								YesNo
		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.	What are the TOTAL wages claimed by you? $
	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?								YesNo
		If Yes, please explain:
	9.	Do you owe any money to the named employer for any reason?								YesNo
		If Yes, how much? $
	10.	Are you covered under a Collective Bargaining Agreement?								YesNo
		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.