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Michigan Occupational Safety and Health Administration
Employment Wage Complaint

A complaint alleging non-payment of wages or fringe benefits must be filed within 12 months of the alleged violation.

If you have not been paid at least minimum wage or you have not been paid overtime, you may file a complaint up to 3 years from the date of the alleged violation.

The online Employment Wage Complaint form may be submitted if you have not been paid your wages or fringe benefits, or if you have not been paid minimum wage or overtime.

Provide any additional information you may have on an attached sheet of paper. Attach copies of any document which supports your claim such as; an employment contract, wage agreement, commission statements, invoices, time records, list of hours worked, check stubs, written fringe benefit (vacation pay, sick pay, holiday pay, paid time off, bonus, expense reimbursement) policy or contract.

EMPLOYEE INFORMATION                            
Last Name:
   
First Name:     Middle initial: 
Address 1:
Address 2:
City:
State:
Zip Code:
County:
Primary Phone: - -
Daytime Phone: - -    (between 8:00 & 5:00 Monday-Friday)
E-mail Address:
Confirm E-mail Address:
Birth Date:  (mm/dd/yyyy)
Last 4 digits of Social
Security Number:  
 
(Optional - This is not a secure site)
Contact Information For Someone Who Will Always Know How To Reach You.   
ADDRESS WHERE YOU WORKED
Street Name & Number:
City:
State:
Zip Code:
County:
EMPLOYER INFORMATION
Business Name:
Type of Business (if known):
Business Address:
City:
State:
Zip Code:
County:
Business Phone: - -  
Fax number: - -  
Was your employment governed by one or more employers? If so, provide the Employer's Name, Address, City, State, ZIP code and telephone number or send an additional sheet listing the information.
E-mail or Website Address:  
List the Approximate Number Of Employees:
Name of Person In Charge of Day-To-Day Operations:
CLAIM WILL BE RETURNED IF AN AMOUNT and PERIOD IS NOT PROVIDED
Nature of Claim
Amount claimed
Period Claimed
Calculate Amount Claimed
ie: $8.00 per hour x 10 hours = $80
(Attach additional sheets if necessary)
Month/Day/Year
to
Month/Day/Year
 (MM/DD/YYYY)
 
(MM/DD/YYYY)
Hourly Wages
$
 
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
$
 
Minimum Wage
$
 
Overtime
$
 
Total Gross (before tax deductions) Amount Claimed
$ 
 
Start date of employment: (mm/dd/yyyy)      Last date worked:   (mm/dd/yyyy)
Employment
Status:

QUIT

STILL EMPLOYED

DISCHARGED

______________________________________________________________________________

LIST YOUR RATE OF PAY (Provide a Copy of your Check Stub): $ Per Hour
$ Salary
If Salaried, How many days/hours were you required to work each week or pay period?
$ Commission
$ Piece Rate / Other ______________________________________________________________________________
How often were you paid? Weekly
Bi-Weekly
Semi-Monthly
Monthly
What was / is your job title?
PLEASE ANSWER THE FOLLOWING QUESTIONS
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.
Are you filing a complaint for pay stubs or wage statements you did not receive?
If yes, please list dates you did not receive a pay stub or wage statement
(MM/DD/YYYY)
If you will be sending us additional information that pertain to your complaint, please check the appropriate button:
  No additional documentation will be sent.
  Check if you will provide attachments by email.
  Check if you will provide attachments by USPS mail.
  Check if you will provide attachments by facsimile (Fax).

MAIL, EMAIL, OR FAX COPIES OF INFORMATION TO:

Wage & Hour Division
PO Box 30476
Lansing, MI 48909-7976
Fax Number: (517) 322-6352
Email Address: 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.


Submitting this form may take between 8 to 10 seconds
Please be patient.


 


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