Wage Complaint Form

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DO NOT USE THIS FORM FOR THE PURPOSES OF FILING AN UNEMPLOYMENT INSURANCE CLAIM. FOR UNEMPLOYMENT INSURANCE CLAIM FILINGS, SELECT 'UNEMPLOYMENT' FROM THE HOME PAGE.

(The following information is necessary for our office to take action). Please answer all questions and include a brief explanation of your complaint.


Person Information

Business Information

Employment Information





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 use my name when contacting the employer listed on the complaint, to receive any monies obtained in payment on this complaint, and hereby authorize the mailing of any payments or other pertinent documents to my address listed on this form.

10/5/2022