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
Office Use Only: CLAIM #:
COMP
INVESTIGATOR:
DATE
RECEIVED:
YOUTH LAW COMPLAINT
This form is used to report employers who may be in violation of the Colorado Youth Employment Opportunity Act. It must be
filled in completely and signed and dated. Failure to do so will delay the processing of this complaint. If you have questions,
please contact the Division by phone at 303-318-8441 or email at cdle_labor_standards@state.co.us.
Complainant Name _________________________________________________________________________________
Mailing Address____________________________________________________________________________________
City_________________________________________________ State_____________ Zip Code _________________
Telephone #________________________ Email Address ___________________________________________________
Relationship to Minor: ☐Self ☐Parent ☐Legal Guardian ☐Other (explain):
Minor Name (if other than complainant)________________________________________________ Age______________
Mailing Address____________________________________________________________________________________
City_________________________________________________ State_____________ Zip Code ________________
Telephone #________________________ Email Address ___________________________________________________
Summary of Complaint (Use additional sheets if neces
sary)
Employer Information
Employ
er Name___________________________________________ Employer Contact__________________________
Mailing Address____________________________________________________________________________________
City_________________________________________________ State_____________ Zip Code____________________
Daytime Telephone #________________________ Alternate Telephone #______________________________________
Employer’s Website ________________________________ Email Address ____________________________________
Dates of Employment: From__________________________________ To______________________________________
By signing this “Youth Law 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
an
ything of value may be subject to criminal prosecution under the laws of the State of Colorado with possible pena
lties of
imprisonment, fines, or both.
I hereby certify that this is a true statement, 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 declare under penalty of perjury 18-5-501, et seq., C.R.S. that the information provided is true and correct.
Name Signature Date
Last up
dated August 2016
Type of Allegation
(check all that apply)
Work schedule / excessive work hours Prohibited occupation
Work restrictions due to age of minor Other (explain) ________________________________
Supporting Documentation:
Pay Statements Paychecks
(check all that apply)
Time Cards Other Information
click to sign
signature
click to edit
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