Complainant Information

1.  FIRST NAME

2. LAST NAME

3. COMPANY NAME

4.  WORK/CELLULAR NO

5.  CONTACT ADDRESS

6. CITY

7. STATE / ZIP CODE

8. EMAIL ADDRESS

Project Information

Note: A separate form must be completed for each project in which you are alleging a violation of prevailing wages.

9.  PROJECT NAME (If known)

10. LIST ADDRESS(ES) OF PROJECT WHERE WORK WAS PERFORMED:

Complaint Against

11. NAME OF BUSINESS/CONTRACTOR/EMPLOYER

12. CONTRACTOR'S STATE LIC. NO

13. ADDRESS OF BUSINESS/CONTRACTOR/EMPLOYER (Include Zip Code)

14.  BUSINESS TEL. NO

15. EMAIL ADDRESS

16. NAME OF PERSON IN CHARGE

17. TITLE

Awarding Body

18. NAME OF PUBLIC AGENCY/AWARDED CONTRACT ENTITY

19. ADDRESS OF AWARDING BODY

20. BUSINESS TEL. NO

21. EMAIL ADDRESS

22. NAME OF PERSON IN CHARGE / TITLE

23. AMOUNT OF CONTRACT

24. FIRST BID AD DATE

25.DATE PROJECT BEGAN

26. PROPOSED FINISH DATE

27. DATE OF NOTICE OF COMPLETION

General Contractor (Prime Contractor)

28. NAME OF GENERAL CONTRACTOR

29. CONTRACTOR?S STATE LIC.

30. ADDRESS

31. BUSINESS TEL. NO

32. EMAIL ADDRESS

33. NAME OF PERSON IN CHARGE

34. TITLE

Prevailing Wage Issues (Email statements substantiating the allegation)

35. BRIEF EXPLAINATION OF ISSUES: (Check all applicable boxes)

Non-payment /Underpayment of wages Yes    No
Not paid travel and subsistence Yes    No
Under reporting of hours  Yes    No
Unpaid overtime/Sat/Sun/Holiday rate  Yes    No
Misclassification of worker  Yes    No
Insufficient fund check  Yes    No
Fringe benefits not paid  Yes    No
Other: 

Apprentice Occupation

36. Trades and Classifications:

Apprentice Violations 1777.5

37. If the contractor is approved to train- Name of the Apprenticeship Committee:

38. Was there a LABOR COMPLIANCE PROGRAM on this project?  Yes    No

If Yes, Name of the LCP:
LCP Telephone Number:

Apprentice Issues

(List any documentation to be provided substantiating the allegation)

39. BRIEF EXPLAINATION OF ISSUES: (Check all applicable boxes)