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WAGE AND HOUR COMPLAINT INSTRUCTIONS (Colorado DORA)

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Colorado Division of Labor Standards and Statistics | 633 17
th
Street, Suite 600 | Denver, Colorado 80202-2107
Main: (303) 318-8441 | Toll Free: 1-888-390-7936 | Fax: (303) 318-8400
Website:www.colorado.gov/cdle/labor | E-mail: cdle_labor_standards@state.co.us
YES
The Division may have the authority to assist you on the
following issues:
NO
The Di
vision does not have authority to assist you on the
following issues:
• Non-payment of wages for work performed in
Colorado for private employers
• Unauthorized or illegal deductions from wages
• Non-payment of overtime in certain industries
• Non-payment of vacation earned in accordance with
an employer’s policy
• Dishonored (bounced) paycheck
• Minimum wage violations in certain industries
• Tip or gratuity disputes
• Ordering payment of owed wages of $7,500 or less
If you are unsure whether your comp
laint is within
the Division’s authority, contact us at:
(303) 318-8441
or
1-888-390-7936
.
• Independent contractor pay disputes
• Work performed outside of Colorado
• Wage complaints already filed in the court system
• Government or school
district employee wages
• Expense reimbursements
• Severance pay
• Sick pay (unless related to the coronavirus
& covered
by the Colorado Health Emergency Leave with Pay
Rules).
• Pay disputes
where an employer filed for bankruptcy
• Wrongful termination
• Discrimination
• Harassment or abusive treatment
• Employment references; slander or libel
• Access to personnel or medical records
• Health or life insurance coverage
• 401K, pension, or savings
accounts
• Taxes
INSTRUCTIONS:
• Answer all questions on the Wage and Hour Complaint Form accurately, and provide a detailed explanation where
necessary. Incomplete forms will delay the processing of the complaint.
• Mail, fax, or email all supporting documents to the Division. Attach copies of any supporting documentation that may
substantiate your complaint,
i.e. checks, timecards, pay statements, employment contracts, policies, and handbooks.
• The supporting documentation you submit should be copies of the original materials. Do NOT send originals.
• Please include your name and the name of the employer on all of the pages of your supporting documents.
• It is important that you provide all information in detail and supply supporting documentation with your initial written
complaint. Failure to supply relevant information will result in delays.
• You are required to contact the Division immediately if your address or contact information changes or if the employer
makes payment of owed wages.
• Promptly respond to any communications from the Division.
• Contact the Division if you have any questions about submitting a complaint.
.
Colorado Division of Labor Standards and Statistics
633 17
th
Street, Suite 600 Denver, Colorado 80202-2107
Telephone (303) 318-8441
Fax (303) 318-8400
Toll Free (888) 390-7936
www.colorado.gov/cdle/labor
cdle_labor_standards@state.co.us
WAGE AND HOUR COMPLAINT INSTRUCTIONS
(used to report employers who may be in violation of Colorado wage and hour laws and regulations)
A wage complaint is a written complaint (using the attached official form) filled out by an employee, and filed with the
Colorado Division of Labor Standards and Statistics (by fax, mail, email or in-person) agai
nst a current or former employer
for unpaid wages that are within the Division's jurisdiction. The wage complaint process is a free service and is available to
current and former Colorado private sector employees, regardless of immigration status. Employees may pursue their wage
complaint through the Division process, or may elect to go to court instead; the Division process is not required in order to
pursue the matter in court. However, if you have already pursued the matter in court, you may not use the Division process.
The Division can order payment of owed wages
up to $7,500.
March 2020
Explanation of the Division’s Wage Complaint Administrative Procedure
• Once a Wage Complaint Form is received, a Compliance Investigator will review it for completeness and determine if
it is within the Division’s authority.
• The Division may contact you to obtain additional information or clarify submitted information.
• Once the Compliance Investigator has determined Division authority and has all of the necessary documentation, a
letter will be sent to the employer explaining the nature of the complaint and the amount alleged to be owed.
• The employer will be given an opportunity to respond to the complaint and provide documentation.
• The Division is required to issue a determination within 90 days of sending the letter to the employer, unless we notify
you in advance of good cause to extend the investigation.
• The Division will send you the determination, along with your rights to appeal a determination or to withdraw from the
Division’s process.
Written Demand for Payment of Wages
Employees who allege that their employer owes them earned
wages may send a written demand for payment of wages. If
full payment is not made within 14 calendar days after the written demand is sent, the employer may be ordered to pay
penalties to the employee, in addition to owed wages. If a written demand is not sent by the employee, the first letter from
the Division to the employer constitutes a written demand. As a courtesy, the Division provides a sample written demand
for payment of wages form on the Division’s website at https://www.colorado.gov/pacific/cdle/complaint-forms
Authorized Representative
If you would like someone else to represent you throughout the Division’s administrative process, please fill out and file
an Authorized Representative Form with the Division. This form is available on our website at
https://www.colorado.gov/pacific/cdle/complaint-forms
Non-English Language Complaints
The Division accepts complaints filed in languages other than English. Spanish speaking Compliance Investigators are
available to address complaints through the Division’s Administrative Procedure. In addition, the Division has access to
interpreter services for other languages.
Retaliation Prohibited
Pursuant to C.R.S. § 8-4-120, employers are forbidden from retaliating or discriminating against an employee for filing a
complaint with the Division. Contact an attorney for legal advice concerning your options if an employer retaliates
against you.
Additional Questions
If you have additional questions, you may contact the Division via phone at 303-318-8441 or 1-888-390-7936 (toll free).
You may also visit our website at www.colorado.gov/cdle/labor or email cdle_labor_standards@state.co.us. The Division
is located at 633 17th Street, Suite 600, Denver, Colorado 80202-2107.
Colorado Division of Labor Standards and Statistics | 633 17th Street, Suite 600 | Denver, Colorado 80202-2107
Main: (303) 318-8441 | Toll Free: 1-888-390-7936 | Fax: (303) 318-8400
Website: www.colorado.gov/cdle/labor | E-mail: cdle_labor_standards@state.co.us
March 2020
Colorado Division of Labor Standards and Statistics| 633 17
th
Street, Suite 600 | Denver, Colorado 80202-2107
Main: (303) 318-8441 | Toll Free: 1-888-390-7936 | Fax: (303) 318-8400
Website: www.colorado.gov/cdle/labor | E-mail: cdle_labor_standards@state.co.us
This form is used to report employers who may be in violation of Colorado wage and hour laws and regulations. This form must
be filled completely, as well as signed and dated. Failure to do so will delay the processing of this complaint.
Section I: Complainant Information
Section II: Employer Information
NAME OF COMPANY (cannot be a government agency or school district) CONTACT NAME (if known)
COMPANY MAILING ADDRESS (often found on pay statements or paychecks) CONTACT PHONE (if known)
CITY STATE ZIP CODE COMPANY PHONE
ADDRESS WHERE YOU WORKED (if different from above) EMAIL ADDRESS
CITY STATE ZIP CODE TYPE OF COMPANY (e.g., construction, restaurant, janitorial, etc.)
Has the company filed for bankruptcy? ☐YES ☐NO ☐UNKNOWN Is the company still in business? ☐YES ☐NO ☐UNKNOWN
Failure to enter the amount of wages owed will delay the processing of this complaint.
Colorado Division of Labor Standards and
Statistics WAGE AND HOUR COMPLAINT
Office Use Only:
CLAIM #:
COMP
INVESTIGATOR
DATE
ASSIGNED:
633 17
th
Street, Suite 600
Denver, Colorado 80202-2107
Telephone (303) 318-8441
Fax (303) 318-8400
Toll Free (888) 390-7936
www.
colorado.gov/cdle/labor
☐MR.
☐MS.
FIRST NAME LAST NAME
PRIMARY PHONE
MAILING ADDRESS ALTERNATE PHONE
CITY STATE ZIP CODE EMAIL ADDRESS
JOB TITLE/POSITION DESCRIBE THE WORK PERFORMED FOR THE EMPLOYER
DATE STARTED WORK
___________
PLEASE CHECK ONE:
☐ STILL EMPLOYED
WITH EMPLOYER ☐ QUIT/RETIRED as of
___________ ☐ TERMINATED as of ___________
Was any of the work for which you are claiming wages performed outside of Colorado?
☐ YES ☐NO
Have you taken legal action against the employer in this matter?
☐ YES ☐NO
Section III: Wage Complaint Information
Check all that apply and enter the corresponding gross amounts claimed (before taxes)
Total Gross Wages Claimed
☐
FINAL WAGES NOT PAID (Complete Worksheet A attached.)
$
☐
HOURS WORKED NOT PAID other than final wages
$
☐
OVERTIME NOT PAID (Complete Worksheets A and B attached.)
$
☐
MINIMUM WAGE NOT PAID (Complete Worksheet A attached.)
$
☐ MEAL OR REST PERIODS WORKED, NOT PAID (Complete Worksheet A attached.)
$
☐
COMMISSION OR BONUS NOT PAID (Complete Worksheet C attached.)
$
☐
VACATION PAY UPON SEPARATION NOT PAID (Attach copy of employer’s vacation policy, if available.)
$
☐
DEDUCTIONS FROM PAYCHECK not permitted by law
$
☐
BOUNCED PAYCHECK (Attach copy, if available.)
$
☐
OTHER (Specify):
$
TOTAL AMOUNT CLAIMED:
$
☐ SICK LEAVE NOT PAID (EMERGENCY RULE - Coronavirus COVID-19)
$
IF YOU BELIEVE SOMEONE ELSE MAY BE LIABLE FOR THIS CLAIM, SUCH AS THE OWNER OR OTHER RESPONSIBLE PARTY, COMPLETE THE FIELDS BELOW:
(If
you would like to list more than one person, please include the below information in an attachment to the complaint.)
OWNER/LIABLE PARTY NAME:
LIABLE PARTY MAILING
ADDRESS:
LIABLE PARTY PHONE:
LIABLE PARTY EMAIL ADDRESS:
March 2020
Colorado Division of Labor Standards and Statistics | 633 17
th
Street, Suite 600 | Denver, Colorado 80202-2107
Main: (303) 318-8441 | Toll Free: 1-888-390-7936 | Fax: (303
) 318-8400
Website: www.colorado.gov/cdle/labor | E-mail: cdle_labor_standards@state.co.us
Section III: Wage Complaint Information continued
RATE OF PAY: ☐ Hour ☐ Month
per ☐ Day ☐ Piece
☐ Week ☐ Other
$__________
How often were
you paid?
☐ Daily ☐ Every other week*
☐ Weekly ☐ Twice monthly*
☐ Monthly
DATE OF MOST RECENT PAYCHECK
(Attach copy of pay stub, if available.)
_____________
*These are not the same. Please call the Division if you have questions.
Section IV: Written Demand sent to Employer for Payment of Unpaid Wages
“Written Demand” means any written demand
for wages from or on behalf of an employee mailed or delivered to the employer’s correct address.
Was a written demand for payment mailed, emailed, or delivered by you to the employer?
☐ YES ☐ NO
If yes, attach proof that the demand was sent to the employer (if available) and complete this section.
Date Demand was mailed, emailed, or delivered
Person to whom Demand was mailed, emailed or delivered
Address where Demand was mailed, emailed, or delivered Date of employer response (Attach copy, if applicable.)
City State
Zip Code
Employer’s reason for not paying wages (if one was provided)
Section V: Non-Wage Complaint Information
TYPE OF COMPLAINT:
☐ Wages Paid, But Not Timely ☐ Itemized Pay Statement(s) not Provided ☐ Rest and Meal Period Violations
(no wages owed)
☐ Other (specify):
Section VI: Additional Information
Explain in detail why you are filing this complaint and show how you calculated the specific amount(s) you are claiming. Attach additional sheets as necessary.
Please also provide copies of any records you have that will help the Division understand your complaint (e.g., time records, company policies, pay stubs, etc.).
Before submitting this wage complaint:
By signing this "Wage and Hour Complaint” you are agreeing to the following:
• I have been notified and understand that any person providing false information to the Division in order to obtain and/or retain anything of value
may be subject to criminal prosecution under the laws of the State of Colorado with possible penalties of imprisonment, fines, or both.
• I hereby certify that this is a true statement of monies owed, and authorize the Division to investigate and assist in this matter.
• I understand that the Division does not guarantee a resolution to this dispute, and that I may have to pursue the matter further in court, with an
attorney, with another agency, or through other methods.
• I understand that any information supplied to the Division may be provided to the employer, the agents of the employer involved in the dispute, and
other agencies or individuals as the Division deems appropriate.
• I understand that the Division cannot legally order the payment of wages in excess of $7,500.
• I declare under penalty of perjury § 18-8-501, et seq., C.R.S. that the information provided is true and correct.
Name Signature Date
Date Received
March 2020
Other Rate:
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Colorado Division of Labor Standards and Statistics | 633 17
th
Street, Suite 600 | Denver, Colorado 80202-2107
Main: (303) 318-8441
| Toll Free: 1-888-390-7936 | Fax: (303) 318-8400
Website: www.colorado.gov/cdle/labor | E-mail: cdle_labor_standards@state.co.us
W
orksheet A - Wages Earned for Time Worked and Unpaid:
Complete this worksheet if you are claiming final wages, hours worked not paid, overtime, minimum wage, meal periods worked not paid.
For Allegations of Unpaid Wages (Regular or Overtime), Please Complete the Table Below.
If additional space is needed, please make copies as needed.
Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Overtime
Hours
Total
Hours
Week
1
Date
Time In
Time Out
Length of
Meal Period
Daily Hours
Week
2
Date
Time In
Time Out
Length of
Meal Period
Daily Hours
Week
3
Date
Time In
Time Out
Length of
Meal Period
Daily Hours
Week
4
Date
Time In
Time Out
Length of
Meal Period
Daily Hours
Hourly Wage: ____________ x Total Hours : _____________ = Amount Earned At Regular Rate: ___________
Overtime Wage: ____________ x Overtime Hours : ____________ = Amount Earned At Overtime Rate: _________________
Amount Earned at Regular Rate:___________ + Amount Earned at Overtime Rate:___________ = Total Earned: _______________
Total Earned:_____________ - Total Paid:_______________ = Amount Claimed:______________________
Worksheet B – Overtime worked and unpaid:
To be used if you are claiming that you are owed for overtime that was not paid. NOTE: Overtime is paid for work performed in
excess of 40 hours per workweek, 12 hours per workday, or 12 consecutive hours.
Workweek
Ending
Hourly
Rate
Overtime
Rate
Number of
Overtime
Hours
Amount
Earned
Amount
Paid
Amount
Owed
1. $ $ $ $ $
2. $ $ $ $ $
3. $ $ $ $ $
4. $ $ $ $ $
5. $ $ $ $ $
6. $ $ $ $ $
7. $ $ $ $ $
8. $ $ $ $ $
Employer’s Workweek (for example, Sunday through Saturday, Monday through Sunday, etc.):_______________________
Total Overtime Hours ____________ x Overtime Rate ____________ = Amount Claimed:____________________
March 2020
Colorado Division of Labor Standards and Statistics | 633 17
th
Street, Suite 600 | Denver, Colorado 80202-2107
Main:
(303) 318-8441 | Toll Free: 1-888-390-7936 | Fax: (303) 318-8400
Website: www.colorado.gov/cdle/labor | E-mail: cdle_labor_standards@state.co.us
Worksheet C – Commission or Bonus:
To be completed if you are claiming you are owed wages for commissions or bonuses that were earned and unpaid. Provide a copy
of the agreement if available. If additional space is needed, please make copies as needed.
1. WHEN ARE COMMISSIONS/BONUSES EARNED?
(i.e.,
date of sale, date of delivery, or date of payment, etc.)
2. WERE COMMISSIONS/BONUSES SUBJECT TO
RETURN, CANCELLATIONS, OR CHARGE BACKS?
☐ YES ☐ NO
IF YES, PLEASE EXPLAIN:
3. DID THE AGREEMENT CALL FOR A DRAW
AGAINST COMMISSIONS/BONUSES?
☐ YES ☐ NO
4. DID YOU SIGN A SEPARATION AGREEMENT? If yes,
provide a copy.
☐ YES ☐ NO
5. IF YOU ANSWERED YES TO #3, EXPLAIN: 6. WAS THERE A WRITTEN COMMISSION OR BONUS
AGREEMENT?
If yes, provide a copy.
☐ YES ☐ NO
COMMISSIONS EARNED
Date of Sale Name of
Customer or
Invoice/
Reference #
Amount of
Sale
Rate of
Commission
Amount of
Commission
Due
Date
Commission
Payable
Date and
Amount Paid
(if any)
Balance Due
Total Amount Owed: $
BONUSES EARNED
Description of Bonus, In
cluding When It Was Earned
Date the Bonus
Was Earned
Gross
Amount
Owed
Total Amount Owed:
$
March 2020
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WAGE AND HOUR COMPLAINT INSTRUCTIONS (Colorado DORA)

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Completed 20 July 2020

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