Prevailing Wage Complaint Form

For Workers on Public Works Projects

Sections 290.210-290.340, RSMo Section 292.675, RSMo 10 Hour Construction Safety Training

Print and mail this form to:
Division of Labor Standards
Attn: Prevailing Wage Program
P.O. Box 449, Jefferson City, MO 65102-0449
Phone: 573-751-3403 Fax: 573-751-3721
E-mail: prevailingwage@labor.mo.gov
www.labor.mo.gov/DLS/prevailingwage

Complainant Information

* The "Asterisk" Denotes Required Field

Salutation:

* First Name:

* Last Name:

Suffix:

Date:

* Address

* City

State

* Zip Code

* Day Phone No.

Alternate Phone No.

* E-mail Address

Confirm E-mail

~ Please Provide e-mail address for confirmation and corespondence about this complaint.

Type of Complaint

Project Identification - Complaint Against

Name of Contractor (Employer)

Name of business as shown on your payroll check

Address

City

State

* Zip Code

County

Phone No.

Alternate Phone No.

General (Prime) Contractor

Subcontractor

* Are you currently employed by this contractor?

Yes

If not, have you ever been employed by this contractor in the past?

Yes

Time employed on this project (month, year)

From:

To:

Type of project:

Building

Heavy

Highway

* Project Name

* Project Location

* City

County

* Contracting Public Body (who is this job for)?

* Project Start and End Date (mm/dd/yyyy) Pursuant to RSMo. 290.290 MODLS can only pursue administrative action for one (1) year from final project payout.

From?

To?

Supporting Documentation

Check stubs/copies of payroll checks

Photos/pictures of project/work performed

Other information (any supporting documentation)

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.

* Summary Of Complaint

*First Name

*Last Name

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.