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JEC Worker Misclassification Complaint Form
JEC Worker Misclassification Complaint Form-Copy
JEC Case Information
a48032317935916847
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Not Given
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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.:
Employer's Fraudulent Activity
Converted
Not keeping proper time records or records or wages/hours worked
Not paying appropriate rate for overtime work (work in excess of 40 hours per week)
Not paying employees for all hours worked
Not paying minimum wage
No unemployment compensation coverage
No Worker's compensation coverage
Not withholding taxes
Requiring employees to underreport hours actually worked
Workers paid off the books wages
Multiple
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All
None
Inverse
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Lookup List
Converted
Not keeping proper time records or records or w...
Not paying appropriate rate for overtime work (...
Not paying employees for all hours worked
Not paying minimum wage
No unemployment compensation coverage
No Worker's compensation coverage
Not withholding taxes
Requiring employees to underreport hours actual...
Workers paid off the books wages
Describe Fraudulent Activity:
Is the employer under reporting/concealing payroll by misclassifying worker(s) as independent contractors?
No
Yes
The occupation(s) involved:
The number of workers:
How the payroll is being concealed:
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Not Given
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Us State
Telephone Number
Cell Phone:
Email
Please Note
**If you want a copy of this form, print it before submitting**
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a48032317976106252
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