Minimum Wage Complaint Form

May the Department of Labor use your name in contacting your employer?    Yes No

Person Submitting Information
First Name:	Last Name:	Social Security No:
Address:		Birthday: --
City:	State:	Zip Code:
Phone:	Email:

Establishment Information
Business Name:	Manager:
Business Phone:	Email:
Address:
City:	State:	Zip Code:
Type of Business (restaurant, store, etc.):
Does the business have 4 or more employees:   Yes No

Employment Information
Employment Dates:   to	Quit Discharged Laid Off Still Employed
Pay Rate $:          Per   Hour Week Month Other
Total Wages Claimed $:	Do you receive gratuities (tips)?      Yes No	Meals?   Yes No
Are any deductions other than state & federal tax & social security taken out of your wages?    Yes No If yes, what kind?
Are other employees receiving less than $7.25 per hour or $2.13 per hour if receiving tips?    Yes No If yes, please enter their Names, Addresses, and Telephone Numbers below:

Briefly explain your complaint below:

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 Safety & Labor Standards to receive any monies obtained as payment on this complaint, and hereby authorize the mailing of it to my address listed on this form.
Signature	Date

Send me a copy.