Minimum Wage Complaint Form
May the Department of Labor use your name in contacting your employer?
Person Submitting Information
Social Security No:
Type of Business (restaurant, store, etc.):
Does the business have 4 or more employees:
Pay Rate $:
Total Wages Claimed $:
Do you receive gratuities (tips)?
Are any deductions other than state & federal tax & social security taken out of your wages?
If yes, what kind?
Are other employees receiving less than $7.25 per hour or $2.13 per hour if receiving tips?
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.
Send me a copy.