Fillable Printable Form 700-027-000
Fillable Printable Form 700-027-000
Form 700-027-000
Department of Labor and Industries
PREVAILING WAGE COMPLAINT
INSTRUCTIONS
F700-027-000 prevailing wage complaint form 01-2009
This form is to be completed only if your complaint is about wages owed for work you performed on a public
works project for a contractor who is working, for example, on a building, road, or janitorial/maintenance project
for a public agency, such as a city, county, state, school district or other public agency.
If your complaint is about general wages not on a public works project, or it is about other worker rights issues, you
must use the Worker Rights Complaint form F700-148-000.
That form may be obtained by calling any L&I office listed on the next page, or at the L&I website:
http://www.lni.wa.gov/WorkplaceRights/
.
The Department of Labor & Industries (L&I) investigates worker rights complaints for prevailing wages including
overtime and unlawful deductions listed in Box 30 on the attached Prevailing Wage Complaint. An Industrial
Relations Agent who works in the county where your employer is located will handle your complaint.
Fill in the form completely to give L&I the facts about your complaint. Use a sheet of paper if you need more
space.
If you move or change telephone numbers, you must give L&I your new address/telephone number: L&I
must be able to contact you for more information or to give you information. Failure to keep L&I informed of your
current address and phone number may delay L&I’s investigation of your complaint and/or lead to a decision that
your employer has not violated the wages you claimed.
Important note regarding wage complaints: L&I cannot guarantee collection of unpaid wages. You do not need
to go through L&I to collect your wages. You may want to talk to a private attorney to learn more about your
ability to pursue a civil lawsuit against your employer to collect unpaid wages. L&I cannot act as your attorney or
give you legal advice about the best course of action for you to pursue unpaid wages from your employer.
Length of investigation: Prevailing wage investigations generally take 180 days to complete. Complicated
investigations may take longer. L&I will contact you when we complete the investigation and make a decision
regarding your complaint.
No confidentiality: To investigate your complaint, L&I will contact your employer. In some cases it will be
necessary for L&I to tell your employer that you filed a complaint.
What information about my complaint should I give to L&I? L&I needs complete information about your hours
and days worked and other information about your complaint. .
• Fill in the attached Prevailing Wage Complaint form completely.
• Give L&I records you have that show your complaint is correct, such as copies of time records, calendars,
or any record of what days and hours you worked, the name of the project or projects where you worked,
and what tasks you did. We will ask your employer for these records also
• Or, explain why you cannot provide these records.
Additional information regarding prevailing wages on public works projects:
• L&I cannot guarantee collection of prevailing wages.
•
Prevailing wage complaints must generally be filed with L&I within 30 days of the project’s acceptance
date by the public agency. Acceptance date means the date the agency formally accepts the project as
completed.
•
If L&I finds a violation of the prevailing wages required under the Public Works Act, RCW 39.12, L&I
will attempt to resolve it with your employer. If L&I cannot resolve the complaint, it may issue a Notice of
Violation to the employer. The employer may appeal and receive a hearing. If this occurs, you have the
right to request to intervene or to participate in the hearing.
•
L&I’s final order, whether favorable or not, will apply to all employees subject to the investigation.
Department of Labor and Industries
PREVAILING WAGE COMPLAINT
INSTRUCTIONS
F700-027-000 prevailing wage complaint form 01-2009
Please mail or take completed complaints to the L&I service location below for the county in which the employer’s business is located.
Please note: The address on the complaint form for Olympia is for the Olympia area only. Mail the envelope to: Industrial Relations Agent,
Department of Labor and Industries, and the appropriate Post Office or street address listed below. Be sure to include the ZIP plus 4 on your
envelope.
Department of Labor and Industries Service Locations
COUNTY CITY MAILING / LOCATION ADDRESS PHONE # /
FAX #
Island
San Juan
Skagit
M
M
O
O
U
U
N
N
T
T
V
V
E
E
R
R
N
N
O
O
N
N
525 East College Way, Suite H
Mount Vernon, WA 98273-5500
(360)
Fax #
416-3000
416-3030
Whatcom
B
B
E
E
L
L
L
L
I
I
N
N
G
G
H
H
A
A
M
M
1720 Ellis Street, Suite 200
Bellingham, WA 98225-4647
(360)
Fax #
647-7300
647-7310
Snohomish
E
E
V
V
E
E
R
R
E
E
T
T
T
T
729 – 100
th
Street S.E.
Everett, WA 98208-3727
(425)
Fax #
290-1300
290-1399
King
S
S
E
E
A
A
T
T
T
T
L
L
E
E
315 – 5
th
Avenue S., Suite 200
Seattle, WA 98104-2607
(206)
Fax #
515-2800
515-2779
B
B
E
E
L
L
L
L
E
E
V
V
U
U
E
E
616 – 120
th
Avenue N.E., Suite C-201
Bellevue, WA 98005-3037
(425)
Fax #
990-1400
990-1445
T
T
U
U
K
K
W
W
I
I
L
L
A
A
(Mailing)
(Street)
P. O. Box 69050, Seattle, WA 98168-1050
12806 Gateway Drive, Tukwila, WA 98168-3346
(206)
Fax #
835-1000
835-1099
Pierce
T
T
A
A
C
C
O
O
M
M
A
A
950 Broadway, Suite 200
Tacoma, WA 98402-4453
(253)
Fax #
596-3945
596-3956
Clallam
Jefferson
Kitsap
B
B
R
R
E
E
M
M
E
E
R
R
T
T
O
O
N
N
500 Pacific Avenue, Suite 400
Bremerton, WA 98337-1943
(360)
Fax #
415-4000
415-4048
P
P
O
O
R
R
T
T
A
A
N
N
G
G
E
E
L
L
E
E
S
S
1605 East Front Street, Suite C
Port Angeles, WA 98362-4628
(360)
Fax #
417-2700
417-2733
Grays Harbor
Lewis
Mason
O
O
L
L
Y
Y
M
M
P
P
I
I
A
A
(Mailing)
(Street)
P. O. Box 44510, Olympia, WA 98504-4510
7273 Linderson Way S.W., Tumwater, WA 98501
(360)
Fax #
902-5313
902-5300
Thurston
Pacific*
A
A
B
B
E
E
R
R
D
D
E
E
E
E
N
N
(Mailing)
(Street)
P. O. Box 66, Aberdeen, WA 98520-0066
415 Wishkah Street, Suite 1-B, Aberdeen, WA 98520-
0013
(360)
Fax #
533-8200
533-8220
Clark
Klickitat
Skamania
V
V
A
A
N
N
C
C
O
O
U
U
V
V
E
E
R
R
312 S.E. Stonemill Drive, Suite 120
Vancouver, WA 98684-6982
(360)
Fax #
896-2300
896-2345
Cowlitz
Pacific*
Wahkiakum
L
L
O
O
N
N
G
G
V
V
I
I
E
E
W
W
900 Ocean Beach Highway
Longview, WA 98632-4013
(360)
Fax #
575-6900
575-6918
Adams*
Grant*
<South of I-90>
Kittitas
Yakima
Y
Y
A
A
K
K
I
I
M
M
A
A
15 West Yakima Avenue, Suite 100
Yakima, WA 98902-3480
(509)
Fax #
454-3700
454-3710
Benton
Columbia
Franklin
Walla Walla
K
K
E
E
N
N
N
N
E
E
W
W
I
I
C
C
K
K
4310 West 24
th
Avenue
Kennewick, WA 99338-1992
(509)
Fax #
735-0100
735-0121
Chelan
Douglas
Grant*
<North of I-90>
E
E
A
A
S
S
T
T
W
W
E
E
N
N
A
A
T
T
C
C
H
H
E
E
E
E
519 Grant Road
East Wenatchee, WA 98802-5459
(509)
Fax #
886-6500
886-6510
Okanogan
M
M
O
O
S
S
E
E
S
S
L
L
A
A
K
K
E
E
3001 West Broadway Avenue
Moses Lake, WA 98837-2907
(509)
Fax #
764-6900
764-6923
Adams*
(S.E.)
Asotin
Ferry
S
S
P
P
O
O
K
K
A
A
N
N
E
E
901 North Monroe Street, Suite 100
Spokane, WA 99201-2149
(509)
Fax #
324-2600
324-2636
Garfield
Lincoln
Pend Oreille
C
C
O
O
L
L
V
V
I
I
L
L
L
L
E
E
298 South Main, Suite 203
Colville, WA 99114-2416
(509)
Fax #
684-7417
684-7416
Spokane
Stevens
Whitman
P
P
U
U
L
L
L
L
M
M
A
A
N
N
(Mailing)
(Street)
P. O. Box 847, Pullman, WA 99163-0847
1250 Bishop Blvd. S.E., Suite G, Pullman WA 99163
(509)
Fax #
334-5296
334-3417
F700-027-000 prevailing wage complaint 01-2009
Department of Labor & Industries
Prevailing Wage Program
PO Box 44540
Olympia WA 98504-4540
(360) 902- or 1-
PREVAILING WAGE
COMPLAINT
Company (Employer) Information
1. Name of business
6. Name of business owner, manager or supervisor
2. Mailing address of business
3. City State ZIP
7. Business phone # 8. Cell phone #
9. FAX #
4. Address where work performed if not at main address
11. Type of business
12. Has company filed for bankruptcy? 13. Is company still in business?
32. Estimate # of workers affected
Worker's Information
14. Your name (last, first, middle initial) Mr. Mrs. Ms.
15. Home address
20. Social Security Number
19. Type of work you performed
23. Date alleged violation occurred
29. List family relationship if related to employer
Yes No Don't know
Yes No Don't know
26. Date of birth, if under 18 when started
work
30. Type(s) of Complaint: Check appropriate box(s). Provide any documents you have to support your prevailing wage claim.
See #38 below.
Final wages not paid
Unpaid overtime
31. Please explain the complaint items checked above.
From To
25. Were you under 18 when employed?
27. If under 18, was parent authorization
form signed?
Yes No
Yes No
33. If this is a wage complaint, did you ask the
employer for your wages?
If yes, state dates you requested your wages.
Yes No
10. When is your scheduled payday?
38. To better assist the investigation, please provide as many of the
following records as possible:
List other records you can provide
34. Are you still working for this employer?
Yes No Fired Quit Laid off Don't know
37. If no longer working for this employer, give the reason(s) for leaving
36. If no longer working for this employer,
list last date worked
35. Date you started working for this
employer
Attendance rosters
Log books
Payroll check stubs
Copies of bad checks
Employee hand book if available
Written wage agreement
Shift schedules
Personal time records
Time card or copy
ESCH #
L&I date stamp
( )
UBI
( )
18. Job title
5. City State ZIP
16. City State ZIP
( ) ( )
( )
24. Rate of pay
$
17. Email address 28. Was work performed in Washington?
Yes No
22. Work phone21. Home phone
Paid at incorrect classification for work performed
Other
Unpaid hours worked
Unauthorized deductions
This form is to be completed only if your complaint is about wages owed for work you performed on a public works project for a
contractor who is working, for example, on a building, road, or janitorial/maintenance project for a public agency, such as a city, county,
state, school district or other public agency.
Wage Information
53. Rate of pay
$ per
Hour Day Week Month
54. Other rate of pay.
Piece rate Commission Sq ft Flat rate Other (specify)
$ per
39. How often are you paid?
Monthly Twice monthly Every other week Weekly Daily
Yes No
40. Do you have a written employment agreement?
41. Are you represented by a union?
Yes No
42. Excluding taxes, have you authorized
any other deductions?
Yes No
If yes, what? If available, provide copy of written authorization
51. Do you have any property belonging to the business?
Yes No
43. Were you paid straight time for overtime hours?
45. Were overtime hours recorded by your employer by another method?
44. Are overtime hours on time cards?
46. Did you receive pay stubs? 47. Do you have your pay stubs?
48. Do you have a record of payment other than pay stubs?
50. Do you have any outstanding loans/advances owing to the business?
If yes, indicate amount owed. $
Yes No
Yes No Yes No Don't know
Yes No
Your Contact Person Information and Signature
75. Please provide information of a contact person NOT living with you who will always know how to reach you. This is necessary in the event
we cannot locate you.
Name
Address
City State ZIP
To the best of my knowledge, the information I have entered on this form is true and accurate.
Yes No Yes No
F700-027-000 prevailing wage complaint 01-2009
59. Reason employer gave for refusing to resolve your complaint or payment of wages
55. From To
56. How many hours due?
Worker Rights Complaint continued
If yes, list:
Yes No
If yes, provide copy
Wages Owed (Documentation requested)
If yes, please provide copies
49. When is/was the scheduled payday for these wages?
76. Date 77. Signature
58. What pay is due you before taxes?
$
Phone number
57. Partial payment received
52. Do you have an attorney who is working to collect the wages for you?
Yes No
Prevailing Wage & Project Information If you are filing a complaint against an employer on more than one project, complete blocks
60-74 for each project. Extra copies of this section may be provided upon request. Prevailing wage investigations generally take 180 days.
Complex complaint investigations may take longer.
67. Prevailing wage rate required
(if known).
$
60. Project name 61. Awarding agency (public entity for whom work is being performed)
62. Name of general contractor (prime contractor)
65. Job classification (type of work performed)
71. Is project completed? 72. Project completion date 73. Place a checkmark in the boxes below for any benefits provided by the employer
Medical Dental Vacation Pension Holidays Other
Yes No
Yes No
74. If "other" is checked in the previous question, please explain other benefit(s)
63. Location where you worked
$
64. Prime Contractor's phone number 66. Hourly rate paid
70. Was an 'Intent to Pay Prevailing Wage' form
posted on the job site?
67. Prevailing wage rate required
(if known)
68. First date you worked on project
$
69. Last date you worked on project
( )
$
RESET
