Employee Wage Claim Form for Non-Payment of Prevailing Wage Rate

The Great Seal of the State of New Jersey

NEW JERSEY DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT

DIVISION OF WAGE AND HOUR COMPLIANCE

PO BOX 389

TRENTON, NEW JERSEY 08625-0389

Employment Information
(First, Middle, Last)
The complete name of a person filing a complaint against an employer for anything except prevailing wages or mandatory overtime complaints
-- (xxx-xx-xxxx)
The federal identification number from the social security administration for the person who is making complaint against employer
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Address of a person filing a complaint against an employer for anything except prevailing wages or mandatory overtime complaints
The home telephone number of a person filing a complaint against an employer for anything except prevailing wages or mandatory overtime complaints
(333)333-3333
The telephone number with message machine of a person filing a complaint against an employer for anything except prevailing wages or mandatory overtime complaints
(333)333-3333
**
The complete name of employer the person is filing a complaint about
**
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
The street address of employer the person is filing a complaint about
The county of the address for employer the person is filing a complaint about
**
The telephone number of employer the person is filing a complaint about
(333)333-3333
(Street)
(Address Line 2)
(City, State, Zip as nnnnn-nnnn or nnnnn)
Employers home address
County part of employers home address
Telephone number of employers home
(333)333-3333
Text description of kind of business
The names of the corporate officers or owners

(** indicates a required field)

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