Wage and Benefit Complaint

EMPLOYEE INFORMATION

* = Required Fields

Last Name

First Name

Middle Initial

Last 4 digits of Social Security Number

(Optional - This is not a secure site)

Birth Date

Address 1

Address 2

City

State

Zip Code

County

Primary Phone

Daytime Phone

Confirm Email

If you provide your email, you will receive an email with this Wage and Benefit Complaint as an attached PDF.

Contact Information For Someone Who Will Always Know How To Reach You

ADDRESS WHERE YOU WORKED

Street Number & Name

City

State

Zip Code

County

Start Date of Employment

Last Date Worked

Employment Status

How Often Were You Paid?

List your Rate of Pay (Provide a Copy of your Check Stub)

Per Hour

Salary

Commission

Piece Rate/Other

If Salaried, How many days/hours were you required to work each week or pay period?

What was / is your job title?

EMPLOYER INFORMATION

Business Name

Type of Business

Business Address

City

State

Zip Code

County

Telephone Number

Fax Number

Email or Website Address of Employer

Name of Person In Charge of Day-To-Day Operations

List the Approximate Number of Employees

Was your employment governed by more than one employer? If so, list the additional Employer's Name, Address, City, State, Zip Code and Telephone Number

CLAIM WILL BE RETURNED IF AN AMOUNT and PERIOD IS NOT PROVIDED

		Period of Claim
Your Reason for Filing this Claim	Amount Claimed	Start	End
WAGES		mm/dd/yyyy	mm/dd/yyyy
Hourly	$

Salary	$

Commissions	$

Piece Rate/Other	$

Unauthorized Deductions	$

FRINGE BENEFITS (Provide written policy or contract)
Vacation Pay	$

Paid Time Off	$

Holiday Pay	$

Sick Pay	$

Expense Reimbursement	$

Bonus	$

Paid Medical Leave	$

Minimum Wage	$

Overtime	$

Total Gross (before tax deductions) Amount Claimed	$

Amount Claimed Calculation

Are you filing a complaint that your employer did not allow you to use paid medical leave?	Yes	No

If yes, please list dates you were not allowed to use your leave.

Are you filing a complaint for pay stubs or wage statements you did not receive?	Yes	No

If yes, please list dates you did not receive a pay stub or wage statement.

PLEASE ANSWER THE FOLLOWING	Yes	No
Have you filed a law suit against the employer on the issues of this claim?

If claiming fringe benefits, was a written policy or contract in effect during your employment? If yes, please provide a copy of the written policy or contract.

Does the business make more than $500,000/year or transport goods outside of Michigan?

Was your employment covered by a union contract? If yes, please submit a copy of the contract.

If you will be sending us additional information that pertain to your complaint, please select the method that they will be sent

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MAIL, EMAIL, OR FAX COPIES OF INFORMATION TO:

Wage and Hour Division
PO Box 30476
Lansing, MI 48909-7976
Fax Number: (517) 763-0110
Email: whclaim@michigan.gov

Filing this complaint does not guarantee payment, or a finding in your favor.

If you are submitting additional documentation by mail to our office, write; "Web filed" at the top, your first and last name, the employer's name and include the online reference number provided at the bottom of the second page of the pdf document sent to you as an attachment to the notification email.

By submitting this claim form online, I certify to the best of my knowledge and belief, this is a true statement of wages or fringe benefits due me. I understand that my claim will be investigated and there is no guarantee that the wage and / or fringe benefits will be found due. I will inform the department if any of the following occur; change of name, address and / or telephone number for myself; or change of employer address; or direct payment and / or settlement of claim.

If you provide an email address, you will receive an email notification that your online complaint form was received, and a copy of your complaint form in pdf format as an attachment.

Please do not submit the complaint more than once.

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Wage and Hour Division