F700-148-000 Worker Rights Complaint Form 07-2024
Worker Rights Complaint
Form Instructions
Do you have the right form? Use this form to file a complaint about:
• Unpaid wages for hours worked or payroll deductions you did not agree to (not including required
taxes).
• Unpaid tips, gratuities, and service charges.
• Paid Sick Leave violations.
• Overtime not paid correctly.
• Meal or rest breaks not provided.
• Problems with uniform reimbursement.
• Youth employment violations.
• Warehouse quota and/or retaliation law were violated.
If your complaint is about something else, see the Complaint Guide
for what form to complete.
All employees in Washington, regardless of immigration status, have a legal right to file a Worker
Rights complaint. We can investigate wage complaints within 3 years of the date you should have been paid.
Learn more about your rights at www.Lni.wa.gov/Workers-Rights
.
Tips for completing this form:
• Try not to skip any questions. Fill out the form clearly and completely. The more information you can
give us, the faster we can help you.
• Send us any documentation you have to support your complaint. Examples include: copies of pay
stubs, time cards, bad checks, signed agreements, any communications with your employer, or even
your personal calendar listing hours worked.
After you file your complaint, we will:
• Contact you to let you know we have received your complaint. We may ask you for more information
before we can start the investigation.
• Contact your employer. L&I will tell your employer that you filed a wage/paid sick leave complaint and
send a copy of your complaint. When investigating wage/paid sick leave complaints, employers must
open their timekeeping and payroll records so we can determine if wages/paid sick leave are owed.
Worker Rights Complaints are subject to public disclosure.
• Investigate your complaint. We will make a decision within 60 days or notify you if we need more time
to investigate.
Complaints we cannot help with:
• A business in which you own at least a 20%
share and actively manage.
• A business that owes money to a company you
own.
• An employer who has filed for bankruptcy. You
may file a “Proof of Claim” with the US
Bankruptcy Court.
• Unpaid vacation, holiday pay, severance pay, or
reimbursement for expenses including fuel.
• Non-Washington-based employees.
• A case you have already filed in court.
If you’re being assisted with your complaint by a lawyer or advocate, please notify the investigating agent.
Continue to next page for form.
F700-148-000 Worker Rights Complaint Form 07-2024
E
mployment Standards Program
360-902-5316 or 1-866-219-7321
Worker Rights Complaint Form
For L&I’s official use to process complaint
WA Unified Business Identifier (UBI):
CATS #:
A. Worker Information
Preferred Language:
English
Spanish
Cambodian
Chinese Simplified
Chinese Traditional
Korean
Laotian
Vietnamese
Other:
Name (As it appears on your ID – First Last Name)
Mailing Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Email Address
Date you started working for this employer
Are you still employed with this employer?
Yes No
If “No”, what was your last day of work?
Reason for leaving job
Fired Quit Laid Off Don’t know
What kind of work did you do?
B. Employer Information
Employer Name (Business Name)
Employer Contact (Owner, Manager, or Supervisor) Name
Employer Mailing Address
City
State
Zip Code
Address Where You Worked (if not the same as above)
City
State
Zip Code
Employer Phone Number
Employer Cell Phone Number
Employer Email Address
Type of Business (for example: construction, restaurant, etc.)
Has the company filed for bankruptcy?
Yes No Don’t Know
Is the employer still in business?
Yes No Don’t Know Bankrupt
C. Wage Complaint Information – Skip to Section D if your complaint is not about wages.
Final wages not paid.
Unpaid tips, gratuities, service charges.
Hours worked not paid.
Overtime not paid correctly.
Minimum wage not paid.
Paid with non-sufficient funds (NSF) check.
Agreed-upon wages not paid.
Unauthorized deductions. Money taken out of
check without my permission (other than taxes).
Paid sick leave (also see Section E).
C
ontinue to next page
F700-148-000 Worker Rights Complaint Form 07-2024
C. Wage Complaint Information Continued
Tell us in detail why you are filing this wage/paid sick leave complaint and what reason your employer gave for not paying. You may
attach additional sheets if you need more room.
Rate of pay per
$
Hour
Day
Week
Month
Other rate of pay per:
$
Piece rate
Commission
Sq. Ft.
Flat Rate
Other (specify)
:
Wages owed:
From: To:
For how many hours?
Partial payment received?
What pay is owed to you before taxes?
$
Reason employer gave for not paying you. You may attach additional sheets if you need more room.
What relevant records are you able to provide to support your wage/paid sick leave complaint? You can either attach copies of your
records to your complaint or submit them later to L&I.
Written wage/employment agreement
Attendance records
Texts, photos, emails
Shift schedules
Pay stubs
Personal time records
Copies of bad checks
Copy of time card(s)
Employee handbook
Records of NSF fees
Sick leave records
Log books
Other:
Have you asked your employer for your wages?
Yes No
If “Yes”, on what dates did you ask?
What were the scheduled payday(s) for the wages you are claiming?
How often are you paid?
Daily Weekly Every other week Twice a month Monthly
Do you have a written employment agreement? If “Yes” attach a copy.
Yes No
Do you belong to a union?
Yes No
If “Yes”, what is your union’s name?
Were you paid straight time for overtime hours?
Yes No
Are overtime hours recorded?
Yes No
Do you receive pay stubs?
Yes No Don’t Know
Do you have pay stubs? If “Yes” attach copies.
Yes No
Do you have an attorney who has filed an action in court to collect these wages?
Yes No If “Yes”, we cannot accept your complaint
Do you owe your employer any money?
Yes No
Amount owed
$
Do you have a written agreement? If “Yes” attach copies.
Yes No
Why?
C
ontinue to next page
F700-148-000 Worker Rights Complaint Form 07-2024
C. Wage Complaint Information Continued
Do you have any property or equipment belonging to the business?
Yes No
If “Yes”, list:
Were you under 18 years old during the period of your complaint?
No Yes If “Yes”, enter your date of birth:
Were other workers affected?
Yes No Don’t Know
If “Yes”, how many?
D. Non-Wage Complaint Information
What type of non-wage complaint are you filing?
Child labor laws were violated.
For example: employer hired under-aged workers or did not follow working-hours rule for teen workers.
Employer did not provide required time for meal periods.
Employer did not provide required time for rest periods.
Employer did not pay for work uniforms.
Warehouse quota and/or related retaliation laws were violated.
Employer retaliated against me.
Other:
Tell us in detail why you are filing this non-wage complaint. You may attach additional sheets if you need more room.
If you have copies of any records that will help us understand your complaint, you will need to provide them.
E. Alleged Type of Paid Sick Leave Violation
Not allowing me to use sick leave.
Not compensating me for paid sick leave used.
Not allowing me to carry over the unused paid sick leave.
Not providing me regular notification of paid sick leave balance.
Other:
When did you ask for leave?
How much leave did you have in the bank?
F. Alternate Contact Information
We need the contact information for someone will always know how to reach you. Please don’t write your own
address or phone number.
Contact Name
Mailing Address
City
State
Zip Code
Home Phone Number
Cell Phone Number
Email Address
Continue to next page
F700-148-000 Worker Rights Complaint Form 07-2024
Required Worker’s Signature
By submitting this form, I am confirming the information provided in accurate and true. I am also
agreeing to cooperate and communicate with my assigned investigator. My name on this form below
constitutes my signature.
Signature (Print or Type)
Date
For more information about your workplace rights and responsibilities in Washington, go to:
www.Lni.wa.gov/WorkplaceRights