Fillable Printable Form 700-146-000
Fillable Printable Form 700-146-000
Form 700-146-000
F700-146-000 Prevailing Wage Complaint Form 08-2017
Prevailing Wage Worker Complaint
Instructions:
Type of prevailing wage complaints L&I accepts:
This form is be completed onlyif your complaint is about wages owed for work you performed in Washington
State on a public works project for a contractor who is working on a building, road, or janitorial/maintenance
project for a public agency such as a city, county, state, school district, or other public agency.
Complaints must be filed within 30 days of the date the public agency accepted the project as
complete.
Important: L&I cannot guarantee the collection of unpaid wages. A private attorney may be necessary to
assess your ability to pursue a civil lawsuit against your employer to collect unpaid wages. L&I cannot act as
your attorney or provide legal advice.
If your complaint is about general wages, not a public works project or it’s about other worker rights issues, you
must use the Worker Rights Complaint form (F700-148-000)
.
You can get a copy of the Worker Rights Complaintform by calling or visiting any L&I office listed on the next
page or online at www.Lni.wa.gov/WorkplaceRights.
Substantiated prevailing wage complaints for non-workers must be filed on the Interested Party Prevailing
Wage Complaint form F700-129-000. That form may be obtained at the following link:
//www.lni.wa.gov/FormPub/Detail.asp?DocID=2190
.
L&I does not accept complaints against abusiness in which you are an owner or against a business that owes
money to a company you own.
How to file your prevailing wage complaint
•Complete and sign the attached form. A separate sheet of paper may be used if you need to explain
your complaint.
•Attach any information or records, such as time sheets/cards, calendars, or any personal records you
have to show the days and hours you worked and the tasks you performed. This is important to
understand your complaint.
•If you are filing a complaint against an employer for work performed in Washington State on more then
one public works project, you must provide project information on all projects in which you are owed
wages (The “Prevailing Wage Project” sectionmust be completedfor each project. Use an additional
sheet ofpaper or make/request additional copies of this section of the form.)
•Mail or bring the form and records to the L&I office in the county where the business is located (see
back of sheet.)
If your prevailing wage complaint is accepted by L&I, we:
•Assign an Industrial Relations Agent to investigate your complaint.
•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.
Important: L&I may receive a request for public records under Washington’s Public Records Act for
records relating to your complaint. After the case is resolved, and possibly during the investigation,
L&I will have to disclose this information to the person requesting the complaint record.
F700-146-000 Prevailing Wage Complaint Form 08-2017
Prevailing Wage Worker Complaint
Mail or take completed forms to the L&I office for the county in where the employer’s business is located. If
there are multiple offices listed, you can send your complaint to any office listed for those counties.
County
L&I Office
Phone/Fax Number
Island
San Juan
Skagit
Whatcom
Mount Vernon
525 East College Way Suite H
Mount Vernon WA 98273-5500
OR
Bellingham
1720 Ellis Street Suite 200
Bellingham WA 98225-4647
Mount Vernon
Phone:360-416-3000
Fax: 360-416-3030
OR
Bellingham
Phone: 360-647-7300
Fax: 360-647-7310
Snohomish
Everett
729 100
th
Street SE
Everett WA 98208-3727
Phone: 425-290-1300
Fax: 425-290-1399
King
Seattle
315 5
th
Ave S Suite 200
Seattle WA 98104-2607
OR
Bellevue
616 120
th
Ave NE Suite C-201
Bellevue WA 98005-3037
OR
Tukwila
12806 Gateway Dr. S
Tukwila WA 98168-3346
Seattle:
Phone: 206-515-2800
Fax: 206-515-2779
OR
Bellevue:
Phone: 425-990-1400
Fax: 425-991-1445
OR
Tukwila
Phone: 206-835-1000
Fax: 206-835-1099
Pierce
Tacoma
950 Broadway Suite 200
Tacoma WA 98402-4453
Tacoma
Phone: 253-596-3945
Fax: 253-596-3956
Clallam
Jefferson
Kitsap
Silverdale
10049 Kitsap Mall BlvdSuite 100
SilverdaleWA 98383
OR
Sequim
542 W. Washington St.
SequimWA 98392
Silverdale
Phone: 360-308-2800
Fax: 360-308-2848
OR
Sequim
Phone: 360-417-2700
Fax: 360-417-2733
Grays Harbor
Lewis
Mason
Thurston
Pacific
Olympia (Mailing)
PO Box 44540
Olympia WA 98504-4540
OR
Aberdeen
415 W WishkahSt Suite 1C
Aberdeen WA 98520-4315
Olympia (Location)
7273 Linderson Way SW
Tumwater WA 98501
Olympia
Phone: 360-902-5335
Fax: 360-902-5300
OR
Aberdeen
Phone: 360-533-8200
Fax: 360-533-8220
Clark
Klickitat
Skamania
Vancouver
312 SE Stonemill DrSuite 120
Vancouver WA 98684-6982
Vancouver
Phone: 360-896-2300
Fax: 360-896-2345
Cowlitz
Pacific
Wahkiakum
Longview
711 Vine Street
Kelso WA 98562-2650
Kelso
360-575-6900
Fax: 360-575-6918
F700-146-000 Prevailing Wage Complaint Form 08-2017
Send completed forms to appropriate office.
See list onprevious page.
Prevailing Wage Worker
Complaint
For L&I Use onlyFor L&I Use only
L&I Date Stamp:
UBI:
CATS -HUB#:
Employer Information
Name of Company
Name of Company owner, manager, or supervisor
Company Mailing Address
Company Phone
Company Cell Phone
City
State
Zip
Fax
E-mail address if known
Address where you worked if not at the above address
Type of Company (i.e: construction, janitorial)
City
State
Zip
Has the company filed for bankruptcy?
Yes No Don’t know
Is the company still in business?
Yes No Don’t know
Worker Information
Language preference (Check one)
EnglishSpanishRussianKoreanChinese
VietnameseLaotianCambodian
Other___________________________
Your name (last, first, middle initial) Mr. Mrs.Ms.
Social Security Number
Mailing Address
City
State
Zip
Home Phone Number
Cell Phone Number
Email Address
Was the work performed in
Washington?
YesNo
Important:
IF you or your attorney have already filed a complaint about these wages in court, we
cannot accept your claim.
F700-146-000 Prevailing Wage Complaint Form 08-2017
Wage Complaint Information
Type(s) of Complaint:
(You may check more than one box)
Unpaid Hours Worked (Paid at correct rate – just not for all hours worked)
Fringe (Usual) Benefits:
(Employer took a fringe credit but benefits were not provided and/or not bona fide and/or
credit calculated wrong.)
Paid at incorrect classification for work performed or failure to pay the prevailing rate of pay.
(Employer paid me at the wrong prevailing wage rate and/or did not pay prevailing wage.)
Unpaid Overtime (Overtime is unpaid and/or calculated at the wrong rate)
Unauthorized Deduction
(Employer made a deduction from my gross wages that I did not authorize.)
Failure to file (check all that apply)Intent Affidavit Certified Payroll
False Filing (check all that apply)Intent Affidavit Certified Payroll
Tell us in detail why you are filing this complaint: You may attach additional sheets if you need more room.
Provide any document(s) you have to support your prevailing wage claim
Were other workers affected?Yes No
If yes, how
many?
_______________________
Did you ask the employer for your
wages?
Yes No
If yes, state
dates:
_______________________
Are you still working for this employer?
Yes No
Date you started? _________________
If no longer working for this employer, give reason: Quit Fired Laid Off Don’t Know
Other: ________________________________________________________________________
Date last worked:_______________
To better assist the investigation, please
provide as many of the following records as
possible.
List other records you can provide
Written wage
agreement
Attendance rosters
__________________________________________
Shift schedules
Log Books
__________________________________________
Personal time
records
Payroll check
stubs/statements
__________________________________________
Time Card
Copies of bad
checks
__________________________________________
Copies of any
correspondence
Employee
Handbook/Manual
__________________________________________
How Often are you paid?
Monthly
Bi-Monthly
Weekly
Bi-Weekly
Daily
Other_______________
Do you have a written employment agreement? YesNo If yes, provide copy
F700-146-000 Prevailing Wage Complaint Form 08-2017
Are you represented by a union?
Yes No
Excluding taxes, have you authorized any other deductions?
Yes No
If yes, what? If available, provide copy of written authorization.
Were you paid straight time for
overtime hours?
Yes No
Are overtime hourson time cards?
Yes No
Did your employer record overtime
hours by another method?
Yes No Don’t know
Did you receive pay stubs?
Yes No
Do you have your pay stubs?
Yes No
If yes, please provide copies
Do you have a record of payment
other than pay stubs?
Yes No
When is/was the scheduled payday for these wages?
__________________________________________
Do you have an attorney who is working to collect the
wages for you? YesNo
If yes, we cannot accept your complaint.
What wages do you believe are owed to you?
Rate of Pay per:
Hour Day WeekMonth
$_______________
Other rate of pay per: Piece rate Commission Sq ft
Flat Rate Other ____________
$_______________
Wages owed:
$____________
From _________ -_________
For how many hours?
_______________
Did you receive partial
payment?
Yes No
What pay is owed to you
before taxes?
_________________
Reason employer gave for not paying you:
Prevailing Wage Project Information:
If you are filing a complaint against an employer on more than one project, please complete a
separate “Prevailing Wage Project Information” section for each project. You do not need to
complete the whole complaint form for each project.
Project Name
Awarding agency (public entity for whom work is being performed)
Name of general contractor (prime contractor)
Location where you worked
Prime contractor’s phone number
Job classification (type of workperformed)
Hourly rate paid
Prevailing wage rate required
(if known)
$_______________
First day you worked on
project
_____________________
Last date you worked on
project
______________________
Was an “Intent to Pay
Prevailing Wages: form posted
on the job site?
YesNo
Is the project
completed?
Yes No
Project completion
date:
_______________
Place a check mark in the boxes below for any benefits provided by the
employer:
Medical Dental Vacation Pension HolidayOther
If “other” is checked in the previous question, please explain other benefit(s)
Continue to next page
F700-146-000 Prevailing Wage Complaint Form 08-2017
Contact Person Information
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. (Must be different address and phone number than your
own.)
Your Contact’s Name
Address
City
State
Zip
Contact phone number
Contact cell phone number
Contact work phone number
Worker Signature Required
Signature
Date
