Worker Rights Complaint Form

Instructions
What types of worker rights complaints can L&I accept?
L&I accepts complaints on the Worker Rights Complaint Form for. . .
In Section C of the form: In Section D of the form:
• Unpaid minimum wages, overtime, final pay, or • Meal or rest periods not given.
hours worked.
• Payroll deductions you did not agree to, not • Violations of child labor laws.
including deductions for required taxes.
• Unpaid tips, gratuities, service charges. • RN or LPN overtime law not followed.
• Paid sick leave. • Employer retaliated against me.
 IMPORTANT: If we find that your employer owes you money, we cannot guarantee that we will be able to
collect it for you. Also, you have three years from the payday your wages were due to file your complaint.
Please keep this in mind when you decide to file your complaint with us.
On separate complaint forms, L&I also accepts for the following complaints. . .
Prevailing Wage Complaint form (F700-146-000) for prevailing wage violations.
Protected Leave Complaint form (F700-144-000) for family leave, family care, leave for victims of domestic
violence, sexual assault or stalking, spouse military leave, leave for voluntary firefighters on the scene.
See the L&I Workplace Rights website for filing the various workplace rights complaints at
[Link]/WorkplaceRights. See the section titled “Complaints/Discrimination”.
We do not accept wage complaints against. . . Or when it’s about. . .
• A business in which you are a part owner • Unpaid vacation, holiday pay, severance pay, or
(including family-owned). reimbursement for expenses including fuel.
• A business that owes money to a company you • If you are claiming wages for hours worked out-
own. of-state for a non-Washington employer.
• Employers who have filed for bankruptcy. You • Bank fees you paid because your employer’s
may file a “Proof of Claim” with the US check bounced.
Bankruptcy Court. • A case you have already filed in court.

How to file your wage complaint:

• Complete and sign the attached form, use a sheet of paper if you need more space to explain your
complaint.
• Attach any information or records, such as time sheets or cards, calendars, or any personal records you
have that show the days and hours you worked and what tasks you did. This is very important to help
us understand your complaint.
• Mail or bring the form and records to the L&I office in the county where the business is located. See back
of page.
 IMPORTANT: If you are moving, have a new telephone number, or are hiring an attorney, let us know
right away. Call the local office where you filed your complaint or 1-866-219-7321. If we can’t contact you,
this may delay the investigation or prevent us from being able to help you.

If we can accept your complaint, we will:

• Assign an Industrial Relations Agent to investigate your complaint. In most cases, L&I must tell your
employer that you filed a complaint and send a copy of your complaint to the employer.
• Make a decision on your complaint within 60 days OR if we have good cause, notify you that we require
more time.
 IMPORTANT: If we cannot take your complaint, you have the right to either contact a private attorney OR
file a suit in Small Claims Court for up to $5000.
[Link]/newsinfo/resources/broc-hure_scc/[Link]

F700-148-000 Worker Rights Complaint Form 01-2018

 Where to file your complaint
In person: OR By mail:
Bring your completed form to the L&I office Mail the original of your completed form to the
located in the same county where your L&I office located in the same county where your
employer’s business is: employer’s business is. Write on the envelope:
“Industrial Relations Agent, Dept. of Labor &
Industries,” then the address of the office you
selected.
L&I Offices
County where Use this L&I Address Phone
you worked office(s) Number
Island 525 East College Way Suite H
Mount Vernon 360-416-3000
San Juan Mount Vernon WA 98273-5500
Skagit 1720 Ellis Street Suite 200
Bellingham 360-647-7300
Whatcom Bellingham WA 98225-4647
729 100th Street SE
Snohomish Everett 425-290-1300
Everett WA 98208-3727
616 120th Avenue NE Suite C-201
Bellevue 425-990-1400
Bellevue WA 98005-3037
King
12806 Gateway Drive S
Tukwila 206-835-1000
Tukwila WA 98168-3346
950 Broadway Suite 200
Pierce Tacoma 253-596-3945
Tacoma WA 98402-4453
10049 Kitsap Mall Blvd Suite 100
Clallam Silverdale 360-308-2800
Silverdale WA 98383
Jefferson
542 W Washington Street
Kitsap Sequim 360-417-2700
Sequim WA 98392
Grays Harbor PO Box 44810 Olympia WA 98504-4810
Olympia 360-902-5799
Lewis 7273 Linderson Way SW Tumwater WA 98501
Mason
Thurston 415 Wishkah Street Suite 1-C
Aberdeen 360-533-8200
Pacific* Aberdeen WA 98520-0013
Clark
312 SE Stonemill Drive Suite 120
Klickitat Vancouver 360-896-2300
Vancouver WA 98684-6982
Skamania
Cowlitz
711 Vine Street
Pacific* Kelso 360-575-6900
Kelso WA 98626-2650
Wahkiakum
Adams*
Grant* (south of I-90) 15 West Yakima Avenue Suite 100
Yakima 509-454-3700
Kittitas Yakima WA 98902-3480
Yakima
Benton
Columbia 4310 West 24th Avenue
Kennewick 509-735-0100
Franklin Kennewick WA 99338-1992
Walla Walla
Chelan East 519 Grant Road
509-886-6500
Douglas Wenatchee East Wenatchee WA 98802-5459
Grant (north of I-90) 3001 West Broadway Avenue
Okanogan Moses Lake 509-764-6900
Moses Lake WA 98837-2907
Adams* (SE)
Asotin 901 North Monroe Street Suite 100
Spokane 509-324-2600
Ferry Spokane WA 99201-2149
Garfield
Lincoln
Pend Oreille
PO Box 847 Pullman WA 99163-0847
Spokane
Pullman 1250 Bishop Blvd SE Suite G 509-334-5296
Stevens
Pullman WA 99163
Whitman

F700-148-000 Worker Rights Complaint Form 01-2018

 Worker Rights Complaint Form
WA Unified Business Identifier (UBI):
Employment Standards Program
360-902-5316 or 1-866-219-7321 CATS #: NAICS #:

A: Worker Information
Language Preference (check one) English Spanish Russian Korean Chinese Simplified Chinese Traditional
Vietnamese Laotian Cambodian Other:
Name (Last, First, MI) Mr. Mrs. Ms. Social Security Number (optional) Home Phone Number Cell Phone Number

Home Address Complaint is for this period of time Your Pay Rate
From: To: $
City State Zip Code Date you began work with this employer Are you still employed with company
Yes No
Email Address If not still with this employer, last date employed Reason for leaving job
Fired Quit Laid Off Don’t know
What kind of work did you do?

B: Employer Information
Name of Company Name of Company Owner, Manager, or Supervisor

Company Mailing Address Company Phone Number Company Cell Phone Number

City State Zip Code Company Fax Number Company Email Address, if known

Address where you worked if not at the above address Type of Company (for example: construction, restaurant, janitorial)

City State Zip Code Has the company filed for bankruptcy? Is the company still in business?
Yes No Don’t know Yes No Don’t know

C: Wage Complaint Information (Skip to Section D if your complaint is not about wages.)
 Important: If you or your attorney have already filed a complaint about these wages in court, we cannot accept your claim.
What type of complaint are you filing? You may check Tell us in detail why you are filing this complaint. You may attach additional sheets if you
more than one box below. need more room.
Final wages not paid Overtime not paid
Minimum wage not Willful failure to pay
paid agreed wages
Money taken out of Unpaid tips,
my paycheck (not gratuities, service
taxes) without my charges
permission*
Paid with NSF check Paid sick leave
(bounced check) (also see Section E)
Hours worked not paid
* If you had a written agreement with your employer to deduct
wages from your paycheck that wasn’t followed correctly, we
will need a copy.
If you have copies of any records that will help us understand your complaint, please attach them to this
form.
What wages do you believe are owed to you?
Rate of pay per Hour Day Week Month Other rate of pay per: Piece rate Commission Sq. Ft. Flat rate Other (specify)
$ $ __________
Wages owed: For how many hours? Partial payment received? What pay is owed to you before taxes?
From: To: $ $
Reason employer gave for not paying you:

F700-148-000 Worker Rights Complaint Form 01-2018

C: Wage Complaint Information (Continued)
Check the box(es) below to show what records you are attaching Have you ever asked your employer for When was the scheduled payday for the
to support your claim: your wages? Yes No wages you are claiming?
Written wage agreement Payroll check stubs If “Yes”, on what dates did you ask?
Shift schedules Copies of bad checks
Personal time records Employee handbook How often are you paid?
Time card or copy Sick leave records Monthly Twice monthly Every other week Weekly Daily
Attendance rosters Other: Do you have a written employment Do you belong to a union?
Log books agreement? Yes No Yes No If “Yes”, what is your
Note: We also will be asking your employer for records. If “Yes”, attach a copy. union’s name?
Were you paid straight time for Are overtime hours recorded? Did you receive pay stubs? Do you have pay stubs?
overtime hours? Yes No Yes No Yes No Yes No If “Yes”, attach copies.
Do you have an attorney who has filed an action Do you owe your employer any money? Do you have any property belonging to the
in court to collect these wages? Yes No Yes No If “Yes”, amount owed: $______ business? Yes No
If “Yes”, we cannot accept your complaint. Why: __________________________________ If “Yes”, list:
Were you under 18 when employed? Written agreement? Yes No
Yes No If “Yes”, attach a copy.
If under 18 when you started work for this Were other workers affected? Yes No
employer, date of birth: If so, how many?

D: Non-Wage Complaint Information

What type of non-wage complaint are you filing? Tell us in detail why you are filing this complaint. You may attach
Child labor laws were violated. (For example: employer hired under- additional sheets if you need more room.
aged workers or did not follow working-hours rule for teen workers.)
Employer did not provide required time for meal periods
Employer did not provide required time for rest periods.
Employer did not pay for work uniform.
RN or LPN nurse overtime rules were not followed.
Employer retaliated against me.
If you have copies of any records that will help us understand your complaint, please
Other: attach them to this form.

E: Alleged Type of Paid Sick Leave Violation

Not allowing me to use sick leave. When did you ask for leave?
Not compensating me for paid sick leave used. How much leave did you have in the bank?
Not allowing me to carry over the unused paid sick leave.
Not providing me regular notification of the paid sick leave balance.
Other:

F. If We Cannot Reach You. . .

 We need contact information for someone who will always know how to reach you.
(Please don’t write your own address or phone number.)
Your Contact’s Name

Address

City State Zip Code

Home Phone Number Cell Phone Number Work Phone Number

REQUIRED WORKER’S SIGNATURE

To the best of my knowledge, the information I have entered on this form is true and accurate.

Signature Date

For more information about your workplace rights and responsibilities in Washington, to go:
[Link]/WorkplaceRights

F700-148-000 Worker Rights Complaint Form 01-2018 RESET