eWage Portal

JEC Worker Misclassification Complaint Form

JEC Worker Misclassification Complaint Form-Copy

JEC Case Information 

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
Location of Work Site(s) (If different than business address:)
Is worksite active now?* How many workers at this site?
Type of Work/Services Performed: Be specific about the work or services performed, such as carpentry, roofing, food services, delivery, health care, etc.:

Employer's Fraudulent Activity 


Describe Fraudulent Activity:
 
 
Dates of occurrence from: To:
 
 

REQUESTOR INFORMATION - Fill In 

First Name Last Name
 
Address 1 City State Zip
       
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.