Free Nonpayment of Wage Complaint Form - Massachusetts


File Size: 39.5 kB
Pages: 4
Date: December 19, 2008
File Format: PDF
State: Massachusetts
Category: Court Forms - State
Author: knorton
Word Count: 1,084 Words, 6,857 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.mass.gov/Cago/docs/Workplace/wageandhour_complaintform.pdf

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Preview Nonpayment of Wage Complaint Form
THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE ATTORNEY GENERAL
FAIR LABOR DIVISION ONE ASHBURTON PLACE BOSTON, MASSACHUSETTS 02108
(617) 727-2200 (617) 727-3465 HELPLINE WWW.MASS.GOV/AGO

Re: Wage Complaint Form Instructions Please fill out this form as completely and accurately as possible. Also, attach photocopies of any supporting information such as pay stubs, work logs, and correspondence from your employer. Please keep the originals for your records. Return the completed form and materials to: Office of the Attorney General Fair Labor Division One Ashburton Place, Rm 1813 Boston, MA 02108 Before we can process your complaint, our office must receive full and complete information from you. Please check to make certain you have provided the following: · · · · · · · · · · Your employer's complete name and address, including zip code Description of the work you performed Amount of wages you are owed, and your hourly or weekly rate of pay Exact dates worked but not paid City or town where you worked Last date you worked Date you made a personal demand to your employer for unpaid wages, and your employer's response Copies of pay stubs If you claim unpaid vacation, include a copy of your employer's vacation policy Any information that would

After reviewing the material you provide, the Attorney Generals Office will determine whether or not conduct a preliminary investigation and whether further action is warranted. This may include the following: · · · Seeking restitution of your unpaid wages Issuing a civil citation against your employer Seeking criminal charges against your employer

If the Attorney General elects to institute a criminal or civil enforcement action, you will be required to be interviewed by and investigator from this office. Later, you may also need to appear at a hearing. If you wish to file your own lawsuit, ninety days after filing a complaint with this office, you may sue your employer in civil court for your wages, plus triple damages and legal fees. You may also request written permission from the Attorney General's Office to proceed before the end of the ninety day waiting period. Please note that it usually takes several weeks to review and conduct a preliminary investigation of your complaint. Your complaint may be forwarded to your employer for response.

Wage/Workplace Complaint Form

Page 1 of 4

Rev. 12/2008

THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE ATTORNEY GENERAL
FAIR LABOR DIVISION ONE ASHBURTON PLACE BOSTON, MASSACHUSETTS 02108
Non-Payment of Wage and Workplace Complaint Form- Page 1
Please provide as much information as you can on this form and mail it to the above address.
(617) 727-2200 (617) 727-3465 HELPLINE WWW.MASS.GOV/AGO

Employee Information First name Social Security Number* Current mailing address City Home phone Emergency contact name and phone
(friend / family member who can reach you)

Middle name Date of birth

Last name Gender M
(month/day/year)

F

State

Zip Cell phone

Email

Mailing address

City

State

Zip

Start date of employment
(month/day/year)

End date of employment
(month/day/year)

Please Read: Under most circumstances, the text of your complaint will be considered a public record and be available to any member of the public upon request. In response to such a request, we generally will not disclose your name, address, phone number, or any other information that identifies you and will not disclose this form in response to any request that specifically seeks the complaint you submitted. Your record in its entirety may, however, be disclosed to law enforcement and regulatory agencies who may assist in resolving your complaint.
*Providing a Social Security Number is voluntary. It will aid in processing your complaint, but we will proceed without one.

Wage/Workplace Complaint Form

Page 2 of 4

Rev. 12/2008

THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE ATTORNEY GENERAL
FAIR LABOR DIVISION ONE ASHBURTON PLACE, ROOM 1813 BOSTON, MASSACHUSETTS 02108
Non-Payment of Wage and Workplace Complaint Form- Page 2
Name of Employee: _______________________________________________________________________________
(617) 727-2200 (617) 727-3465 HELPLINE WWW.MASS.GOV/AGO

Do you speak English? Yes

No

What language would you prefer we contact you in?

What type of work did you perform? Name of employer Are you currently working for this employer? Yes If applicable, reason for end of employment? Quit Did you sign a contract with the employer? Yes Is an attorney representing you? Yes No No No ___ Discharged ____ No

Has a community organization or union helped you file this complaint? Yes

If yes, please provide name(s) of the attorney, organization, or union; as well as a contact person, address, and phone number.

Did you ask to get paid the wages you are owed? Yes If yes, what was the employer's response?

No

Have you taken any other action against the employer regarding this problem? Yes If yes, please explain.

No

An employer does not have the right to threaten, discriminate, or retaliate against you because of your efforts to collect wages. If this has happened to you, please explain.

Wage/Workplace Complaint Form

Page 3 of 4

Rev. 12/2008

THE COMMONWEALTH OF MASSACHUSETTS OFFICE OF THE ATTORNEY GENERAL
FAIR LABOR DIVISION ONE ASHBURTON PLACE, ROOM 1813 BOSTON, MASSACHUSETTS 02108
Non-Payment of Wage and Workplace Complaint Form- Page 3
(617) 727-2200 (617) 727-3465 HELPLINE WWW.MASS.GOV/AGO

Employer Information. Please provide as much information as you can. Company name Other business name(s) used by employer Company address Company owner/president name Owner/president home address Owner/president phone (workplace, cell, and/or home) If known, total number of employees in company City/town(s) where work was performed Reason for Filing Complaint. Check all that apply and provide details below. If you are not sure which category applies, just describe your situation below.
Minimum wage violation Non-payment of wages Vacation pay violation*
*If possible, please attach a copy of the company vacation policy.

City

State License plate number(s)

Zip

City

State

Zip

Local manager/supervisor name(s)

Meal period violation Overtime pay violation Sunday overtime/holiday pay

Child labor Unpaid commissions Failure to provide personnel records Other
(specify "Other")

Time period of violation(s) is from
(month/day/year)

to
(month/day/year)

.

Your most recent rate of pay? $

per hour or week (circle one) Total amount owed? $

Please provide detailed information about what happened and what you are owed.

CERTIFICATION: I hereby certify that, to the best of my knowledge and belief, this is a true and accurate statement of the facts about my complaint.

Signature

PRINT your name

Date signed

Wage/Workplace Complaint Form

Page 4 of 4

Rev. 12/2008