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:
*
Amount Owed:
Daytime Phone:
(8:00AM - 4:30PM)
*Type*
Cell
Home
Work
Other
Optional Phone:
*Type*
Cell
Home
Work
Other
Period of Employment:
- From Date:
*
- To Date:
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:
ADAIR
ALLEN
ANDERSON
BALLARD
BARREN
BATH
BELL
BOONE
BOURBON
BOYD
BOYLE
BRACKEN
BREATHITT
BRECKINRIDGE
BULLITT
BUTLER
CALDWELL
CALLOWAY
CAMPBELL
CARLISLE
CARROLL
CARTER
CASEY
CHRISTIAN
CLARK
CLAY
CLINTON
CRITTENDEN
CUMBERLAND
DAVIESS
EDMONSON
ELLIOTT
ESTILL
FAYETTE
FLEMING
FLOYD
FRANKLIN
FULTON
GALLATIN
GARRARD
GRANT
GRAVES
GRAYSON
GREEN
GREENUP
HANCOCK
HARDIN
HARLAN
HARRISON
HART
HENDERSON
HENRY
HICKMAN
HISPANIC
HOPKINS
JACKSON
JEFFERSON
JESSAMINE
JOHNSON
KENTON
KNOTT
KNOX
LARUE
LAUREL
LAWRENCE
LEE
LESLIE
LETCHER
LEWIS
LINCOLN
LIVINGSTON
LOGAN
LYON
MADISON
MAGOFFIN
MARION
MARSHALL
MARTIN
MASON
MCCRACKEN
MCCREARY
MCLEAN
MEADE
MENIFEE
MERCER
METCALFE
MONROE
MONTGOMERY
MORGAN
MUHLENBERG
NELSON
NICHOLAS
OHIO
OLDHAM
OTHER
OUT-OF-STATE
OWEN
OWSLEY
PENDLETON
PERRY
PIKE
POWELL
PULASKI
ROBERTSON
ROCKCASTLE
ROWAN
RUSSELL
SCOTT
SHELBY
SIMPSON
SPENCER
STATEWIDE
TAYLOR
TODD
TRIGG
TRIMBLE
UNION
WARREN
WASHINGTON
WAYNE
WEBSTER
WHITLEY
WOLFE
WOODFORD
*
- 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