Complaint

EMPLOYMENT COMPLAINT FORM
por Español

EDUCATION AND LABOR CABINET
DIVISION OF WAGES AND HOURS
500 MERO STREET, 3RD FLOOR
FRANKFORT KY 40601-4220
Telephone: (502)564-3534 ~ Fax: (502)696-1897
www.labor.ky.gov

Personal Information

* Indicates mandatory field

First Name:	*
Last Name:	*
SSN:	*
Home Address:	*
- City:	*
- State:	*
- Zip:	*
Email Address:

How were you paid while employed?
Hourly Salary Other (Comm., Piece Rate, etc...)
Pay Rate:	* Numeric
Amount Owed:	Numeric
Daytime Phone: (8:00AM - 4:30PM)
Optional Phone:
Period of Employment:
- From Date:	* mm/dd/yyyy
- To Date:	mm/dd/yyyy

Job Title and briefly describe your Job Duties: (50 words max)		*
Nature of Complaint: (150 words max)		*

Business Information

Business Name:	*
Business Phone:	*
Contact Person:
Contact Title:
Kentucky Address:	*
- City:	*
- County:	*
- Zip:

Out of State Home Office Address (if applicable):
- Address:
- City:
- State:
- Zip:

Submit Complaint

By submitting this complaint form, you are certifying the above information is complete and accurate. Additionally, you are stating this is your valid signature authorizing the Kentucky Labor Cabinet to use your name in the investigation of your referenced employer.

I agree with the above statement.

I wish to submit a complaint, but choose to not use my name in the investigation.

Exit and file a paper complaint

Department of Workplace Standards