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To be completed by the complainant:

* Indicates required information.

Complainant information

Enter your full name in box 1
Enter your address in box 2 a
State requires 2 characters
Zip Code Length must be between 5 and 10 numeric characters
Enter your city in box 2 b Enter your state in box 2 c Enter your zip in box 2 d
Enter your country in box 2 e
Enter your phone number in box 4

Respondent information

Enter the name of the employer in box 7
Enter the address of the employer in box 8 a
State requires 2 characters
Zip Code Length must be between 5 and 10 numeric characters
Enter the city of the employer in box 8 b Enter the state of the employer in box 8 c Enter the zip of the employer in box 8 d

11. Statement

Explain as clearly as possible. Attach any pertinent documentation at the end of this form.
You must complete box 11 a
You must complete box 11 b
You must complete box 11 c
You must complete box 11 d
You must complete box 11 e

12. Electronic signature:



Enter your name in box 12
I CERTIFY the information furnished is true and accurate to the best of my knowledge. I AUTHORIZE the disclosure of this information as needed for the proper investigation and enforcement of my complaint. I UNDERSTAND my identity will be kept confidential to the maximum extent possible, consistent with applicable law and a fair determination of my complaint. I also understand it is against the law for my employer to discharge, intimidate, retaliate, coerce or discriminate against me for filing this complaint.
Enter your name as signed in the signature box
8/19/2026
14. The customer submitting this complaint either requested assistance or submitted the complaint form by email or on paper. I have completed this form based on the information provided by the customer to the best of my ability.

Upload files

You may attach up to five supporting documents. NOTE: Each file must be less than 5 MB in size. Only the following file types are allowed: pdf, bmp, gif, jpg, jpeg, png