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
Number, Street, Ap
t., or P.O. Box No.
City, State, ZIP Code
including area code): ___________________
en You Can Be Reached at that Number: _________________________________________________________________
E-Mail Address (
2. Nature of Source’s Relationship to
Employer (Please check all that apply)
1B H-1B1 E-3
Former or Curre
nt Employee (dates of employment): _______
(b) U.S. Worker
Former Current Employee (
dates of employment): __________________________________
(c) Job Applicant (date of application): ___________________________________________________________________
(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): ____ ___________________________________________________________________________
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Rev. May 2015
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3. Information on Employer Committing Alleged Violation(s)
e of Employer/Company
ess: ____ ___________________________________________________________________________________________________
Number, Street City, State
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).
supplied incorrect or false information on the Labor Condition Application (LCA).
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.
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.
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.
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
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.
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.
required nonimmigrant worker(s) to pay all or any part of the scholarship and training fee (ACWIA fee).
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
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).
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.
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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: _________
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,
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
plaint Received/Taken By: Date:
Source of Complaint is: Aggrieved party Credible source
Rev. May 201
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