Name of complainant Social Security Number Current address of complainant (Street/City/State/Zip Code) Permanent address, if different from current address Telephone (including area code) (Home/Cell/Other) E-Mail address Project name, location and contract/project number Prime contractor company name Employer (company) name Employer: name of owner/responsible party Employer address Employer: contact information (Telephone/Cell/Other) Current employee Check one: Period employed on the project Former employee To: From: (specify) Occupation/job title: Duties performed (be specific) used and/or equipment operated Other (specify): Wage Rate: $ per Hour Day Week Piece Hours usually worked on the project Sunday Monday Tuesday Wednesday Thursday Friday Saturday Usual start and stop times Start work time: End work time: Name of complainant Social Security Number
Name of complainant Social Security Number Current address of complainant (Street/City/State/Zip Code) Permanent address, if different from current address Telephone (including area code) (Home/Cell/Other) E-Mail address Project name, location and contract/project number Prime contractor company name Employer (company) name Employer: name of owner/responsible party Employer address Employer: contact information (Telephone/Cell/Other) Check one: Current employee Former employee (specify) Period employed on the project From: To: Occupation/job title: Duties performed (be specific) used and/or equipment operated Wage Rate: $ per Hour Day Week Piece Other (specify): Hours usually worked on the project Sunday Monday Tuesday Wednesday Thursday Friday Saturday Usual start and stop times Start work time: End work time: Name of complainant Social Security Number
10-p-federal-labor-standards-complaint-intake-form-hud-4731-06.2004-exp-08.31.10.docx