Employee Classification Act Complaint Form

LB 563- Requires that every individual working for a contractor (individual, business entity engaged in construction, or trucking/delivery services, including all subcontractors) has the right to be properly classified as an employee rather than an independent contractor if the individual does not meet the requirements of an independent contractor under the law.

Complaint Information
First Name:	Last Name:	Social Security No:   - -
Address:
City:	State:	Zip Code:
Phone:    ( ) -	Email:
Dates of Employment:       From: / /          To: / /

Contractor Information
Business Name:	Owner:
Business Phone:    ( ) -	Email:
Address:
City:	State:	Zip Code:
Location/Address of Jobsite or where work was being performed:		Contractor Registration Number:

Other Contractors You Have Worked For In Previous 12 Months:
1.	Name:	Phone:    ( ) -
	Address:
2.	Name:	Phone:    ( ) -
	Address:
3.	Name:	Phone:    ( ) -
	Address:

Other Possible Misclassified Workers:
1.	Name:	Phone:    ( ) -
	Address:
2.	Name:	Phone:    ( ) -
	Address:
3.	Name:	Phone:    ( ) -
	Address:

I hereby certify that this is a true statement to the best of my knowledge and belief. I authorize the Nebraska Department of Labor, Office of Labor Standards 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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