DLSE-PW-Form 1 - English

Summary

DLSE-PW-Form 1 - English

Text

Instructions: Please complete as much information as you are able.
Please email complaint to [email protected] 
or mail to 2031 Howe Avenue, Suite 100, Sacramento, CA 95825
 
NAME   EMAIL   
HOME PHONE # CELL PHONE #
MAILING ADDRESS CITY STATE/ZIP 
ALTERNATE CONTACT NAME ALTERNATIVE CONTACT EMAIL
CONTACTS RELATION TO YOU ALTERNATE CONTACT PHONE #
NAME OF CONTRACTOR BUSINESS PHONE #
MAILING ADDRESS CITY STATE/ZIP
 
NAME OF PROJECT  
NAME OF AWARDING BODY (Example: City of, County of, School District, Department of)
START DATE YOU WORKED ON PROJECT END DATE YOU WORKED ON PROJECT
LOCATION/ADDRESS(ES) OF PROJECT 
NAME OF BUSINESS BUSINESS PHONE #
MAILING ADDRESS CITY STATE/ZIP CODE
Unpaid/underpaid Overtime or Sat/Sun rate Underreporting of hours
Unpaid/underpaid holiday (indicate holiday) Non-payment/underpayment of wages
Unpaid/underpaid fringe benefits Misclassification of worker
Unpaid/underpaid Travel & Subsistence Insufficient funds (bounced check)
Brief narrative of allegations:
STATE OF CALIFORNIA - Labor Commissioner's Office
Department of Industrial Relations
Division of Labor Standards Enforcement
PUBLIC WORKS - WORKER COMPLAINT
PREVAILING WAGE ISSUES
GENERAL (PRIME) CONTRACTOR
PROJECT INFORMATION
YOUR INFORMATION
COMPLAINT AGAINST (Employer Information)

What was your job classification?
Describe the work you did and the tools you used
What was your straight time or regular rate of pay?    
Did you work on Saturday, Sunday or holiday?   Yes ____    No ____.  If so, what was your rate of Pay? ____________
Did you receive any of the following benefits?   
(Health Insurance - Yes ____ No ____)         ( Pension - Yes ____ No ____)
(401 K - Yes ____ No ____)        (Vacation - Yes ____ No ____)       (Travel - Yes ____ No____)   
(Optional)  List  information of coworkers (or witnesses)
name of worker phone email
address
name of worker phone email
address
name of worker phone email
address
name of worker phone email
address
name of worker phone
email
address
Please attach anything else that may be helpful in pursuing your claim.
Signature Date
DLSE-PW 1 (Revised December 2025)
WORKER INFORMATION

Retrieval chunks

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  Instructions: Please complete as much information as you are able. Please email complaint to [email protected] or mail to 2031 Howe Avenue, Suite 100, Sacramento, CA 95825 NAME EMAIL HOME PHONE # CELL PHONE # MAILING ADDRESS CITY STATE/ZIP ALTERNATE CONTACT NAME ALTERNATIVE CONTACT EMAIL CONTACTS RELATION TO YOU…