Sections 290.500-290.530, RSMo

To submit this form electronically, complete form and click "Submit"
at bottom of the form.

"*" Indicates Required Fields
To mail, print and complete this form and send to:
Division of Labor Standards
Attn: Minimum Wage Program
P.O. Box 449, Jefferson City, MO 65102-0449
Phone: 573-751-3403   Fax: 573-751-3721
  ( -   ( -
Please Provide e-mail address for confirmation and corespondence about this complaint.
*Type of Complaint
(Please check all appropriate boxes.)

  By signing the verification below, I waive my right of
  confidentiality pursuant to Section 290.520 and authorize
  the Division of Labor Standards to use my name during the
  investigation of my complaint.
 ( -   ( -
Type of Complaint If no longer employed, state reason:                                

If you are unable to attach the documentation electronically, please indicate below in the "Summary of Complaint" a brief description of documentation you have. An investigator may contact you and ask to have it mailed or faxed to our agency if the documentation is needed.

Please provide a brief description of your job duties and explain why you feel you have not been appropriately paid under the Missouri Minimum Wage Law.
By entering my name and submitting this electronically,
I do hereby affirm under penalties of perjury that the above-stated information is true and correct to the
best of my knowledge, information, and belief.