Fillable m il Prevailing Wage Complaint Form (Minnesota)

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m il Prevailing Wage Complaint Form (Minnesota)

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The m il Prevailing Wage Complaint Form (Minnesota) form is 2 pages long and contains:

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  • 125 other fields

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File type: PDF

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Prevailing Wage Complaint Form
Minnesota Department of Labor and Industry
Labor Standards
Prevailing Wage
443 Lafayette Road North
St. Paul, MN 55155-4341
Phone: 651-284-5091 Fax: 651-284-5740
www.dli.mn.gov
PRINT IN INK or TYPE your responses.
COMPLAINANT INFORMATION
NAME
HOME TELEPHONE
ADDRESS WORK TELEPHONE
CITY STATE ZIP CODE CELL TELEPHONE
E-MAIL ADDRESS OTHER TELEPHONE
PROJECT INFORMATION
PROJECT NAME
PROJECT NUMBER
PRIME CONTRACTOR
ADDRESS
COUNTY
ADDRESS
CITY STATE ZIP CODE TELEPHONE
TYPE OF CONSTRUCTION:
Road Bridge Building Trail Airport Other
IS THE PROJECT COMPLETE?
Yes No Unknown
EMPLOYER INFORMATION
NAME
Are you still employed by this employer?
Yes No
ADDRESS TELEPHONE If NO, last date worked:
CITY STATE ZIP CODE
Was your termination?
Voluntary Involuntary
WAGE AND HOUR INFORMATION
Nature of complaint (more than one may apply):
Wage Rate Overtime Fringes Classification
Work performed:
Dates worked on this project:
Total hours worked on this project:
How often were you paid?
Weekly Monthly
Bi-weekly Other
From: To: Regular: Overtime:
Regular hourly rate of pay:
Overtime hourly rate of pay:
Did you work on a shift schedule?
Yes No
If, Yes, which shift? Day Night
Project work Non-project work Project work Non-project work
Were you paid overtime at 1 1/2 times your hourly rate of pay after:
Were you an apprentice?
Yes No
Which trade?
Check Check and Cash Cash Other
Hours worked recorded by: Recorded by foreman
Time card/sheet Called into office Other
Did you receive fringe benefits? Yes No If Yes, select:
Health Insurance Training Vacation Life Insurance
Sick Leave Holidays Pension Other
Did you receive cash payment for fringes? Yes No
If yes, how much?
Yes No If Yes, how much?
Did you receive travel and living expenses?
Yes No How much? hour / day
(over)
n
n n
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EMPLOYEE ON PROJECT
If same as complainant, check here
NAME HOME TELEPHONE
ADDRESS WORK TELEPHONE
CITY STATE ZIP CODE CELL TELEPHONE
E-MAIL ADDRESS
OTHER TELEPHONE
Work Classification: Did you perform work in other classifications?
Yes No
How many hours?
What rate were you paid?
Regular Overtime
Number of affected employees on project:
List work tasks and tools used
Tasks
Tools Used
Nature of Complaint:
Did you operate equipment?
Did you use hand tools?
Yes No If Yes, what type? Yes No If yes, what type?
Did you seed, sod or plant trees and bushes?
Yes
No
Did you work more than 8 feet underground?
Yes
No
Additional Comments:
Does Minnesota Department of Labor and Industry have permission to use your name to resolve this wage
issue? Yes No
To the best of my knowledge, the information that I have provided is true and accurate.
COMPLAINANT SIGNATURE
DATE
Return to:
Minnesota Department of Labor and Industry
Labor Standards
443 Lafayette Road N
St. Paul, MN 55155
This material can be made available in different forms, such as large print, Braille or audio. To request, call 651-284-5091 or 1-800-342-5354.
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m il Prevailing Wage Complaint Form (Minnesota)

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Completed 10 November 2020

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