NDOL | CreateEmpClassificationAct

Employee Classification Act Complaint Form

Your Information

First Name

Last Name

Title

Address

City

State

Zip Code

Phone

SSN

Business Being Reported

What is your relationship to the business?:

Former Worker

Current Worker

Other Worker

If you are a former or current worker, please list dates of employment:

Start Date

End Date

Business Name

Owner

Address

City

State

Zip Code

Phone Number

Email Address

Location/address of jobsite or where work was being performed

Contractor Registration Number

Work Site City

Work Site ZipCode

Complaint Information

Please provide any explanation or information that would be helpful to Nebraska Department of Labor in the investigation of this complaint.

Are there other possible misclassified workers at this business? Please list below, if known.

Name	Address	Phone #

+ Add Worker

I hereby certify that the information provided above is true to the best of my knowledge and belief. I authorize the Nebraska Department of Labor to share the information contained in this complaint with any other government office or agency necessary to fully resolve this complaint.

Signature

Date

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