Wage Theft Complaint Petition
Complainant Information
Full Name
Address
Phone Number
Email
Employer Information
Employer Name
Business Name
Business Address
Phone Number
Email (if known)
Details of Wage Theft
Dates of Employment / Incident
Type of Wage Theft (unpaid wages, overtime, tips, etc.)
Amount Owed
Describe the issue
Steps taken to resolve (if any)
Signature
Signature
Date