Worker Rights Complaint Form (F700 148 000) F700 000

User Manual: F700

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F700-148-000 Worker Rights Complaint Form 01-2018
Worker Rights Complaint Form
Instructions
What types of worker rights complaints can L&I accept?
L&I accepts complaints on the Worker Rights Complaint Form for. . .
In Section C of the form:
In Section D of the form:
•
Unpaid minimum wages, overtime, final pay, or
hours worked.
•
•
Payroll deductions you did not agree to, not
including deductions for required taxes.
•
•
Unpaid tips, gratuities, service charges.
•
•
Paid sick leave.
•
IMPORTANT: If we find that your employer owes you money, we cannot guarantee that we will be able to
collect it for you. Also, you have three years from the payday your wages were due to file your complaint.
Please keep this in mind when you decide to file your complaint with us.
On separate complaint forms, L&I also accepts for the following complaints. . .
Prevailing Wage Complaint form (F700-146-000) for prevailing wage violations.
Protected Leave Complaint form (F700-144-000) for family leave, family care, leave for victims of domestic
violence, sexual assault or stalking, spouse military leave, leave for voluntary firefighters on the scene.
See the L&I Workplace Rights website for filing the various workplace rights complaints at
www.Lni.wa.gov/WorkplaceRights. See the section titled “Complaints/Discrimination”.
We do not accept wage complaints against. . .
Or when it’s about. . .
•
A business in which you are a part owner
(including family-owned).
•
Unpaid vacation, holiday pay, severance pay, or
reimbursement for expenses including fuel.
•
A business that owes money to a company you
own.
•
If you are claiming wages for hours worked out-
of-state for a non-Washington employer.
•
Employers who have filed for bankruptcy. You
may file a “Proof of Claim” with the US
Bankruptcy Court.
•
Bank fees you paid because your employer’s
check bounced.
•
A case you have already filed in court.
How to file your wage complaint:
•
Complete and sign the attached form, use a sheet of paper if you need more space to explain your
complaint.
•
Attach any information or records, such as time sheets or cards, calendars, or any personal records you
have that show the days and hours you worked and what tasks you did. This is very important to help
us understand your complaint.
•
Mail or bring the form and records to the L&I office in the county where the business is located. See back
of page.
IMPORTANT: If you are moving, have a new telephone number, or are hiring an attorney, let us know
right away. Call the local office where you filed your complaint or 1-866-219-7321. If we can’t contact you,
this may delay the investigation or prevent us from being able to help you.
If we can accept your complaint, we will:
•
Assign an Industrial Relations Agent to investigate your complaint. In most cases, L&I must tell your
employer that you filed a complaint and send a copy of your complaint to the employer.
•
Make a decision on your complaint within 60 days OR if we have good cause, notify you that we require
more time.
IMPORTANT: If we cannot take your complaint, you have the right to either contact a private attorney OR
file a suit in Small Claims Court for up to $5000.
www.courts.wa.gov/newsinfo/resources/broc-hure_scc/smallclaims.doc
F700-148-000 Worker Rights Complaint Form 01-2018
Where to file your complaint
In person:
OR
By mail:
Bring your completed form to the L&I office
located in the same county where your
employer’s business is:
Mail the original of your completed form to the
L&I office located in the same county where your
employer’s business is. Write on the envelope:
“Industrial Relations Agent, Dept. of Labor &
Industries,” then the address of the office you
selected.
L&I Offices
County where
you worked
Use this L&I
office(s)
Address
Phone
Number
Island
San Juan
Skagit
Whatcom
Mount Vernon
525 East College Way Suite H
Mount Vernon WA 98273-5500
360-416-3000
Bellingham
1720 Ellis Street Suite 200
Bellingham WA 98225-4647
360-647-7300
Snohomish Everett
729 100th Street SE
Everett WA 98208-3727
425-290-1300
King
Bellevue
616 120th Avenue NE Suite C-201
Bellevue WA 98005-3037
425-990-1400
Tukwila
12806 Gateway Drive S
Tukwila WA 98168-3346
206-835-1000
Pierce Tacoma
950 Broadway Suite 200
Tacoma WA 98402-4453
253-596-3945
Clallam
Jefferson
Kitsap
Silverdale
10049 Kitsap Mall Blvd Suite 100
Silverdale WA 98383
360-308-2800
Sequim
542 W Washington Street
Sequim WA 98392
360-417-2700
Grays Harbor
Lewis
Mason
Thurston
Pacific*
Olympia PO Box 44810 Olympia WA 98504-4810
7273 Linderson Way SW Tumwater WA 98501 360-902-5799
Aberdeen 415 Wishkah Street Suite 1-C
Aberdeen WA 98520-0013 360-533-8200
Clark
Klickitat
Skamania
Vancouver 312 SE Stonemill Drive Suite 120
Vancouver WA 98684-6982 360-896-2300
Cowlitz
Pacific*
Wahkiakum
Kelso 711 Vine Street
Kelso WA 98626-2650 360-575-6900
Adams*
Grant* (south of I-90)
Kittitas
Yakima
Yakima 15 West Yakima Avenue Suite 100
Yakima WA 98902-3480 509-454-3700
Benton
Columbia
Franklin
Walla Walla
Kennewick 4310 West 24th Avenue
Kennewick WA 99338-1992 509-735-0100
Chelan
Douglas
Grant (north of I-90)
Okanogan
East
Wenatchee
519 Grant Road
East Wenatchee WA 98802-5459
509-886-6500
Moses Lake 3001 West Broadway Avenue
Moses Lake WA 98837-2907
509-764-6900
Adams* (SE)
Asotin
Ferry
Garfield
Lincoln
Pend Oreille
Spokane
Stevens
Whitman
Spokane 901 North Monroe Street Suite 100
Spokane WA 99201-2149 509-324-2600
Pullman
PO Box 847 Pullman WA 99163-0847
1250 Bishop Blvd SE Suite G
Pullman WA 99163
509-334-5296
F700-148-000 Worker Rights Complaint Form 01-2018
Worker Rights Complaint Form
WA Unified Business Identifier (UBI):
Employment Standards Program
360-902-5316 or 1-866-219-7321
CATS #:
NAICS #:
A: Worker Information
Language Preference (check one) English Spanish Russian Korean Chinese Simplified Chinese Traditional
Vietnamese Laotian Cambodian Other:
Name (Last, First, MI) Mr. Mrs. Ms.
Social Security Number (optional)
Home Phone Number
Cell Phone Number
Home Address
Complaint is for this period of time
From: To:
Your Pay Rate
$
City State Zip Code
Date you began work with this employer
Are you still employed with company
Yes No
Email Address
If not still with this employer, last date employed
Reason for leaving job
Fired Quit Laid Off Don’t know
What kind of work did you do?
B: Employer Information
Name of Company
Name of Company Owner, Manager, or Supervisor
Company Mailing Address
Company Phone Number
Company Cell Phone Number
City State Zip Code
Company Fax Number
Company Email Address, if known
Address where you worked if not at the above address
Type of Company (for example: construction, restaurant, janitorial)
City State Zip Code
Has the company filed for bankruptcy?
Yes No Don’t know
Is the company still in business?
Yes No Don’t know
C: Wage Complaint Information (Skip to Section D if your complaint is not about wages.)
Important: If you or your attorney have already filed a complaint about these wages in court, we cannot accept your claim.
What type of complaint are you filing? You may check
more than one box below.
Tell us in detail why you are filing this complaint. You may attach additional sheets if you
need more room.
If you have copies of any records that will help us understand your complaint, please attach them to this
form.
Final wages not paid
Overtime not paid
Minimum wage not
paid
Willful failure to pay
agreed wages
Money taken out of
my paycheck (not
taxes) without my
permission*
Unpaid tips,
gratuities, service
charges
Paid with NSF check
(bounced check)
Paid sick leave
(also see Section E)
Hours worked not paid
* If you had a written agreement with your employer to deduct
wages from your paycheck that wasn’t followed correctly, we
will need a copy.
What wages do you believe are owed to you?
Rate of pay per
$
Hour
Day
Week
Month
Other rate of pay per:
$
Piece rate
Commission
Sq. Ft.
Flat rate
Other (specify)
__________
Wages owed:
From: To:
For how many hours?
Partial payment received?
$
What pay is owed to you before taxes?
$
Reason employer gave for not paying you:
F700-148-000 Worker Rights Complaint Form 01-2018
C: Wage Complaint Information (Continued)
Check the box(es) below to show what records you are attaching
to support your claim:
Have you ever asked your employer for
your wages? Yes No
If “Yes”, on what dates did you ask?
When was the scheduled payday for the
wages you are claiming?
Written wage agreement
Payroll check stubs
Shift schedules
Copies of bad checks
Personal time records
Employee handbook
How often are you paid?
Monthly Twice monthly Every other week Weekly Daily
Time card or copy
Sick leave records
Attendance rosters
Other:
Do you have a written employment
agreement? Yes No
If “Yes”, attach a copy.
Do you belong to a union?
Yes No If “Yes”, what is your
union’s name?
Log books
Note: We also will be asking your employer for records.
Were you paid straight time for
overtime hours? Yes No
Are overtime hours recorded?
Yes No
Did you receive pay stubs?
Yes No
Do you have pay stubs?
Yes No If “Yes”, attach copies.
Do you have an attorney who has filed an action
in court to collect these wages? Yes No
If “Yes”, we cannot accept your complaint.
Do you owe your employer any money?
Yes No If “Yes”, amount owed: $______
Why: __________________________________
Written agreement? Yes No
If “Yes”, attach a copy.
Do you have any property belonging to the
business? Yes No
If “Yes”, list:
Were you under 18 when employed?
Yes No
If under 18 when you started work for this
employer, date of birth:
Were other worker affected? Yes No
If so, how many?
D: Non-Wage Complaint Information
What type of non-wage complaint are you filing?
Tell us in detail why are filing this complaint. You may attach additional
sheets if you need more room.
If you have copies of any records that will help us understand your complaint, please
attach them to this form.
Child labor laws were violated. (For example: employer hired under-
aged workers or did not follow working-hours rule for teen workers.)
Employer did not provide required time for meal periods
Employer did not provide required time for rest periods.
Employer did not pay for work uniform.
RN or LPN nurse overtime rules were not followed.
Employer retaliated against me.
Other:
E: Alleged Type of Paid Sick Leave Violation
Not allowing me to use sick leave.
When did you ask for leave?
Not compensating me for paid sick leave used.
How much leave did you have in the bank?
Not allowing me to carry over the unused paid sick leave.
Not providing me regular notification of the paid sick leave balance.
Other:
F. If We Cannot Reach You. . .
We need contact information for someone who will always know how to reach you.
(Please don’t write your own address or phone number.)
Your Contact’s Name
Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Work Phone Number
REQUIRED WORKER’S SIGNATURE
To the best of my knowledge, the information I have entered on this form is true and accurate.
Signature
Date
For more information about your workplace rights and responsibilities in Washington, to go:
www.Lni.wa.gov/WorkplaceRights
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