Fillable Printable Form WH-4

Form WH-4

Nonimmigrant Worker

Information Form

U.S. Department Of Labor

Wage and Hour Division

OMB Control No.: 1205-0310

Expiration Date: 05/31/2018

This report is authorized by the American Competitiveness and Workforce Improvement Act (ACWIA) of 1998. 8 U.S.C.

§§ 1182(n)(2)(G), 1182(t)(3)(A). The information provided on this form will assist the U.S. Department of Labor (

DOL) in determining

whether the named employer of H-1B, H-1B1 or E-3 nonimmigrant(s) has committed a violation of provisions of the applicable

nonimmigrant program. Your identity will be kept confidential to the fullest extent provided by law. 5 U.S.C. § 552(b)(7)(D). Please

provide as much of the requested information as possible. Attach additional sheets if you need additional space to respond to a question.

If you do not understand a term, or need assistance in the completion of this form, please contact the Wage and Hour Division of the

U.S. Department of Labor: 1-866-4USWAGE (1-866-487-9243). After you submit the form, a representative from the DOL may

ontact you if further information is necessary to initiate an investigation.

1. Person Submittin

g Information (please print)

Mr., Miss, Mr

s., Ms.: ______________________________________________________________________________________________

First Name Middle Name Last Name

Current Address:

______________________________________________________________________________________________

Number, Street, Ap

t., or P.O. Box No.

____ __________________________________________________________________________________________

City, State, ZIP Code

Telephone Number

(

including area code): ___________________

__________________________________________________________

Days/Times Wh

en You Can Be Reached at that Number: _________________________________________________________________

E-Mail Address (

optional): _________________________________________________________________________________________

_______________

______________________________________________________________________________________________________

2. Nature of Source’s Relationship to

Employer (Please check all that apply)

(a) Nonim

igr

er H-

1B H-1B1 E-3

Former or Curre

nt Employee (dates of employment): _______

___________________________

(b) U.S. Worker

Former Current Employee (

dates of employment): __________________________________

(d) Co mpetitor Business (please specify): ___________________________________________________________________

(e) Federal Government Agency (please specify): ____ ________________________________________________________

(f) State or Local Government Agency (please specify): ____ ___________________________________________________

(g) Community or Service Organization (please specify): _______________________________________________________

(h) Oth er (please specify): ____ ___________________________________________________________________________

___________________________________________________________________________

Continued on Next Page

Form WH-4

Rev. May 2015

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3. Information on Employer Committing Alleged Violation(s)

Nam

e of Employer/Company

Addr

ess: ____ ___________________________________________________________________________________________________

Number, Street City, State

ZIP Code

Employer Representative to Be Contacted: _____________

______

__________________________________________________________

elephone Number (including area code): ____

____________________________________________________________________

____

____________________________________________________________________________________________________________

Description of Alleged Violation(s)

Please check the

appropriate box(es), (a) through (q), which best describe

the violation of the applicable nonimmigrant worker

provisions of the Immigration and Nationally Act which you believe have occurred.

In Section 8, identify each item checked and describe,

in as much detail as possible, the facts and circumstances which cause you to believe that violations have occurred. (Note. Items m, n, o,

and p do not apply to H-1B1 or E-3 workers).

(a) Em

ployer

supplied incorrect or false information on the Labor Condition Application (LCA).

(b) Employe

r failed to pay nonimmigrant worker(s) the higher of the prevailing or actual wage.

failed to pay nonimmigrant worker(s) for time off due to a decision by the employer (e.g., for lack of work) or

for time needed by the nonimmigrant worker(s) to acquire a license or permit.

) Employer

made deductions from nonimmigrant worker’s wage (e.g., for nonimmigrant petition processing; for food and

housing expenses when the nonimmigrant worker is traveling on the employer’s business; for tools and equipment

necessary to perform employer’s work) that caused the wages paid to fall below the nonimmigrant worker’s required wage.

(e) Employer

failed to provide fringe benefits to nonimmigrant worker(s) equivalent to those provided to U.S. worker(s) (e.g.,

cash bonuses, stock options, paid vacations and holidays, health benefits, insurance, retirement and saving plans.

(f) Employe

r does not afford nonimmigrant worker(s) working conditions (hour, shifts, and vacation periods) on the same

basis as it does U.S. worker(s), or the employment of nonimmigrant worker(s) adversely affects the working conditions of

U.S. worker(s).

(g) Employer

failed to comply with “no strike/lockout” requirement by: 1) placing or contracting out nonimmigrant worker(s)

during the validity period of the LCA to any place of employment where there is a labor dispute; 2) failing to notify the

DOL, within 3 working days of the occurrence, of such a labor dispute; or 3) using an LCA for nonimmigrant worker(s) to

work at a site before the DOL has determined that a labor dispute has ended.

) Employer

failed to provided employees or their collective bargaining representative, either by hard copy posting or

electronically, notice of its intentions to hire nonimmigrant worker(s), or has failed to provide nonimmigrant worker(s)

with a copy of the LCA.

(i) Employer

required nonimmigrant worker(s) to pay all or any part of the scholarship and training fee (ACWIA fee).

(j) Employe

r imposed an illegal penalty (as opposed to liquidated damages permissible under state law) on nonimmigrant

worker(s) for ceasing employment with the employer prior to a date agreed upon by the nonimmigrant worker and the

employer.

(k) Employer

retaliated or discriminated against an employee, former employee, or job applicant for disclosing information,

filing a complaint, or cooperating in an investigation or proceeding about a violation of the applicable nonimmigrant

program laws and regulations (i.e., whistleblower).

(l) Employe

r failed to maintain and make available for public examination the LCA and necessary documents at the

employer’s principal place of business or worksite.

(m) H-1B dependent/willful violator em

ployer laid off U.S. worker(s) and has replaced or seeks to replace U.S. worker(s) with

H-1B worker(s) within 90 days before or after filing H-1B visa petitions.

(n) H-1B dependent/willful violator empl

oyer placed H-1B workers(s) at another employer’s worksite where U.S. workers

have been laid off, and /or has failed to inquire of the second employer whether it has or intends to lay-off U.S. worker(s)

and replace them with H-1B worker(s).

(o) H-1B dependent/willful violator empl

oyer failed to recruit U.S. worker(s) for jobs for which H-1B worker(s) are sought.

_____________________________________________________________________________________________________________________

Continued on Next Page

Form WH-4

Rev. May 201

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(p) H-1B dependent/willful violator employer failed to hire a U.S. worker who applied and was equally or better qualified for

the job for which the H-1B worker was sought. Complaints alleging failure to offer employment to an equally or better

qualified U.S. worker, or a misrepresentation regarding such offer(s) of employment, may be filed with the U.S.

Department of Justice, Office of Special Counsel for Immigration-Related Unfair Employment Practices, 950 Pennsylvania

Avenue, NW., Washington, DC 20530.

(q) Other: _________

___________________________________________________________________________________

_______

__________________________________________________________________________________________________

_______

__________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

5. Date(

s) of Alleged Violation(s): _____________

________________________________________________________________________

6. Location of Wor

ksite(s) where Alleged Violation(s) occurred: ____

_____________________________________________ __________

Basis of Knowledge of Alleged Violation(s): ______

________

____________ ________________________________________________

8. Description o

f facts and circumstances which support allegations in Sec

tion 4, ite

ms (a) through (q). Use additional sheets of paper,

if necessary.

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

________________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

_______

_________________________________________________________________________________________________________

________________________________________________________________________________________________________________

_______

______________________________________________________________________________________________________________

Notice.

Persons are not required to respond to an information collection unless it displays a cur

rently valid OMB control number These

reporting instructions have been approved under the Paperwork Reduction Act. Obligations to reply are voluntary. Immigration and Nationality

Act, section 212(n)(G)(ii). Public reporting burden for this collection of information is estimated to average 20 minutes per response, including

the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of

information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for

reducing this burden, to the U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

_____________________________________________________________________________________________________________________

FOR DOL U SE ONLY

Com

plaint Received/Taken By: Date:

Source of Complaint is: Aggrieved party Credible source

Form WH-4

Rev. May 201

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