Wage Complaint Form
Title of form: Wage complaint form
This form is used for complaints under the Pennsylvania Minimum Wage Act of 1968 and the Wage Payment and Collection Law.


Claimant Information

 
 
 
   
 
 
 
 
 
 
 
    
  
   
 
   
 
   



Employer Information
 

First Name of Contact Person
 
 
 

First Name of Owner
 
 
 

 
 
 
 
 
 
 
 
     
   
 



Additional Employer Information




Complaint Details
    
  Are you still employed by the named employer?
  (mm/dd/yyyy)  
  Was your termination:
  1. Was there a written contract of employment between you and the named employer?
  2.   
  If Other, please explain:
  3.
  If Yes, please explain:
    4. What was the latest rate of pay agreed upon between you and the named employer?
      
 
   5.  
  6.

NOTE: Failure to provide detailed information in the space provided above may make it impossible to pursue this claim on your behalf.
  7.
  8.
  If Yes, please explain:
  9.
    If Yes, how much? $  
  10.
  If Yes, list the name and address of the union:
 




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.
   

 
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