JEC Worker Misclassification Complaint Form

JEC Worker Misclassification Complaint Form-Copy

JEC Case Information

COMPANY INFORMATION - Fill In

Company Name*

Also Known As (doing business as):

	Telephone:	Cell:

Name(s) of Business Owner(s):

Supervisor/Foreman Name:

	Federal Employer ID Number (Appears on W2 or 1099 Form)

	Owner's Social Security Number (If Known)


Business Address (include city, state, and zip code if known):

	Address (Number and Street)	City	State	Zip
			Us State

Location of Work Site(s) (If different than business address:)

Is worksite active now?*	How many workers at this site?
No Yes

Type of Work/Services Performed: Be specific about the work or services performed, such as carpentry, roofing, food services, delivery, health care, etc.:

Is the employer under reporting/concealing payroll by misclassifying worker(s) as independent contractors?

No Yes

Dates of occurrence from:	To:

Do you preform services for this company?

No Yes

Anonymous (Please Note: If you choose to be anonymous, you cannot contact us for updates.)

REQUESTOR INFORMATION - Fill In

First Name		Last Name

	Address 1			City		State		Zip
						Us State

	Telephone Number		Cell Phone:

	Email

Please Note

**If you want a copy of this form, print it before submitting**

Please make sure to upload files before submitting.

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JEC Worker Misclassification Complaint Form