Minimum Wage or Overtime Complaint Form
Title of form: Wage complaint form
This form is used for complaints under the Pennsylvania Minimum Wage Act of 1968.


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.   
  If Other, please explain:
  2. What was the your rate of pay?
      
 
  3. How often do you work over 40 hours per week?
  4. Do you have Statement of Earnings(Pay Stubs) showing hours of work, rate of pay, etc.?
  5. Did you retain your own record of hours worked?
 



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.
   
 
 
 
Contact UsCommonwealth PortalContact the Web Team | Privacy PolicyDisclaimer
Copyright ©  Commonwealth of Pennsylvania