Form EPA-1 Equal Pay Act Complaint - California

Form EPA-1 or the "Equal Pay Act Complaint" is a form issued by the California Department of Industrial Relations.

Download a PDF version of the Form EPA-1 down below or find it on the California Department of Industrial Relations Forms website.

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Equal Pay Act Complaint
FOR OFFICE USE ONLY
Taken by:
Office:
Employee Name:
Date filed:
Violation:
Case #:
PLEASE PRINT OR TYPE ALL INFORMATION
Refer to the accompanying Guide to assist you in filling out this form.
Action:
SIC #:
PRELIMINARY QUESTIONS
**The following questions are asked in relation to your current complaint **
1.
Do you claim you were paid less than an employee of the opposite sex, of another race, or of another ethnicity, who is performing substantially similar
work?
YES
NO
If Yes, is the pay disparity based on:  SEX  RACE  ETHNICITY
Provide your demographic information related to the basis of your claim i.e. provide your SEX if pay disparity is based on SEX.
SEX:
RACE: (Mark all that apply)
ETHNICITY:
 Female
 American Indian, Native American, Alaskan Native
 Hispanic or Latino
 Male
 Asian
 Non-Hispanic or Latino
 Other____________
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Other _________________________
2. Did you speak with a Labor Commissioner Investigator during an inspection at your worksite?
YES, on:
/
/
(DD/MM/YY) Name of Investigator:
___ ___________
NO
3. Have you made a previous wage claim against your employer with the Labor Commissioner? In which District Office? ______________________
YES, on:
/
/
(DD/MM/YY)
NO [ If you have unpaid wages, you may file a wage claim
by filling out another form,
DLSE Form
1.
4. Are other employees also filing Equal Pay Act (California Labor Code §1197.5) claims against your employer?
YES
NO
I DON’T KNOW
Part 1: LANGUAGE ASSISTANCE & REPRESENTATION
5a. Do you need an interpreter?
5b
If you checked “YES” to Box 5a, enter language needed: ______________________________
.
Y
N
6a. If you are being helped with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME
6b. ADVOCATE’S PHONE
and ORGANIZATION:
(
)
CITY
STATE
ZIP CODE
6d. ADVOCATE’S EMAIL
6c. ADVOCATE’S MAILING ADDRESS
(Number, Street, Floor, Suite)
Part 2: EMPLOYER INFORMATION
7. EMPLOYER / BUSINESS NAME(S)
8.
9.
EMPLOYER’S VEHICLE LICENSE PLATE #
EMPLOYER’S PHONE
(
)
CITY
STATE
ZIP CODE
10. ADDRESS of EMPLOYER / BUSINESS
(Street Number, Street Name, Floor, Suite):
CITY
STATE
ZIP CODE
11. ADDRESS where you worked, if different from Box 10
(Number, Street, Floor, Suite):
12. NAME of PERSON IN CHARGE
13. JOB TITLE / POSITION of PERSON IN CHARGE
(First Name, Last Name)
16. TOTAL NUMBER OF
17.
14. TYPE OF BUSINESS
15. TYPE OF WORK PERFORMED
EMPLOYER STILL IN BUSINESS?
EMPLOYEES
□ YES ☐ NO
□ I DON’T KNOW
18. Check which box describes your employer: ☐CORPORATION ☐INDIVIDUAL/DBA ☐PARTNERSHIP ☐LLC ☐LLP ☐I DON’T KNOW
Part 3: EMPLOYMENT STATUS
18. Are you still employed by the employer?
YES
NO
If you checked “NO”, indicate reason:
QUIT
DISCHARGED
SUSPENDED
Other (specify): _______________
20. If you no longer work for the employer, what was your final rate of pay? $
/
(for example, $10/hour)
EPA-1 (August 2017)
(Page 1 of 3)
Equal Pay Act Complaint
FOR OFFICE USE ONLY
Taken by:
Office:
Employee Name:
Date filed:
Violation:
Case #:
PLEASE PRINT OR TYPE ALL INFORMATION
Refer to the accompanying Guide to assist you in filling out this form.
Action:
SIC #:
PRELIMINARY QUESTIONS
**The following questions are asked in relation to your current complaint **
1.
Do you claim you were paid less than an employee of the opposite sex, of another race, or of another ethnicity, who is performing substantially similar
work?
YES
NO
If Yes, is the pay disparity based on:  SEX  RACE  ETHNICITY
Provide your demographic information related to the basis of your claim i.e. provide your SEX if pay disparity is based on SEX.
SEX:
RACE: (Mark all that apply)
ETHNICITY:
 Female
 American Indian, Native American, Alaskan Native
 Hispanic or Latino
 Male
 Asian
 Non-Hispanic or Latino
 Other____________
 Black or African American
 Native Hawaiian or Other Pacific Islander
 White
 Other _________________________
2. Did you speak with a Labor Commissioner Investigator during an inspection at your worksite?
YES, on:
/
/
(DD/MM/YY) Name of Investigator:
___ ___________
NO
3. Have you made a previous wage claim against your employer with the Labor Commissioner? In which District Office? ______________________
YES, on:
/
/
(DD/MM/YY)
NO [ If you have unpaid wages, you may file a wage claim
by filling out another form,
DLSE Form
1.
4. Are other employees also filing Equal Pay Act (California Labor Code §1197.5) claims against your employer?
YES
NO
I DON’T KNOW
Part 1: LANGUAGE ASSISTANCE & REPRESENTATION
5a. Do you need an interpreter?
5b
If you checked “YES” to Box 5a, enter language needed: ______________________________
.
Y
N
6a. If you are being helped with your claim by a lawyer or other advocate, enter your ADVOCATE’S NAME
6b. ADVOCATE’S PHONE
and ORGANIZATION:
(
)
CITY
STATE
ZIP CODE
6d. ADVOCATE’S EMAIL
6c. ADVOCATE’S MAILING ADDRESS
(Number, Street, Floor, Suite)
Part 2: EMPLOYER INFORMATION
7. EMPLOYER / BUSINESS NAME(S)
8.
9.
EMPLOYER’S VEHICLE LICENSE PLATE #
EMPLOYER’S PHONE
(
)
CITY
STATE
ZIP CODE
10. ADDRESS of EMPLOYER / BUSINESS
(Street Number, Street Name, Floor, Suite):
CITY
STATE
ZIP CODE
11. ADDRESS where you worked, if different from Box 10
(Number, Street, Floor, Suite):
12. NAME of PERSON IN CHARGE
13. JOB TITLE / POSITION of PERSON IN CHARGE
(First Name, Last Name)
16. TOTAL NUMBER OF
17.
14. TYPE OF BUSINESS
15. TYPE OF WORK PERFORMED
EMPLOYER STILL IN BUSINESS?
EMPLOYEES
□ YES ☐ NO
□ I DON’T KNOW
18. Check which box describes your employer: ☐CORPORATION ☐INDIVIDUAL/DBA ☐PARTNERSHIP ☐LLC ☐LLP ☐I DON’T KNOW
Part 3: EMPLOYMENT STATUS
18. Are you still employed by the employer?
YES
NO
If you checked “NO”, indicate reason:
QUIT
DISCHARGED
SUSPENDED
Other (specify): _______________
20. If you no longer work for the employer, what was your final rate of pay? $
/
(for example, $10/hour)
EPA-1 (August 2017)
(Page 1 of 3)
PRINT YOUR EMPLOYER’S NAME:
FOR OFFICE USE ONLY
Part 4: YOUR COMPLAINT
INSTRUCTIONS
: Please see the Instructions Sheet to help you answer the following questions. Give a written statement to each question. An
incomplete form will result in delays. While it is important to know the names of management involved, do not include the names of any of your
witnesses on this page.
21. What is your job title and/or occupation?
22. What are your job duties?
23. How much are you paid? Include all your compensation (wages, bonuses, commissions, other).
24. Who are the employees being paid more than you?
Employee 1
a.
Name:____________________________________________
b. Job Position:________________________________________
c.
Job Duties:_____________________________________________________________________________________________________
d.
Sex, Race, Ethnicity:_____________________________________________________________________________________________
e.
Location:______________________________________________________________________________________________________
f.
Wage Rate (Include all of this employee’s compensation):________________________________________________________________
Employee 2
a.
Name:____________________________________________
b. Job Position:________________________________________
c.
Job Duties:_____________________________________________________________________________________________________
d.
Sex, Race, Ethnicity:_____________________________________________________________________________________________
e.
Location:______________________________________________________________________________________________________
f.
Wage Rate (Include all of this employee’s compensation):________________________________________________________________
If there are more than two employees, please attached an additional sheet with more information.
25.
Have you asked your employer why you are paid less than your co-worker?
YES
NO
d.
If yes, what was the employer’s response? Are the reasons that your employer gave untrue? Please explain.
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
e.
If no, what reason do you think the employer would give to explain the unequal pay?
26. Do you believe that you have also been retaliated against because you exercised your rights under the Equal Pay Act? If so, fill out and submit the
“Retaliation Complaint” form (RCI-1)
EPA-1 (August 2017)
(Continued, Page 2 of 3)
PRINT YOUR EMPLOYER’S NAME:
FOR OFFICE USE ONLY
*THIS PAGE IS CONFIDENTIAL*
Part 5: YOUR INFORMATION
The name of the complainant shall be confidential until the Labor Commissioner establishes the validity of the
complaint, unless the complainant’s name must be disclosed to investigate the complaint. The complainant’s name
shall remain confidential if the complaint is withdrawn before the complainant’s name is disclosed.
27. Your FIRST NAME
28. Your LAST NAME
29. HOME PHONE
30. OTHER PHONE
31. BIRTH DATE
(
)
(
)
CITY
STATE
ZIP CODE
32. Your MAILING ADDRESS
(Street Number, Street Name, Apartment Number)
33. EMAIL
34. Your Date of Hire
_/
_/
(DD/MM/YY)
NEW EMPLOYMENT
Have you started a new job? ☐Yes ☐No
Date you started new job:
/
_/
(DD/MM/YY)
)
Name of New Employer:
Rate of pay: $
/
(for example, $10/hour
Part 6: WITNESSES
All witnesses are kept confidential. The Labor Commissioner will not reveal their identities unless it becomes
necessary to proceed with the investigation or to enforce the Labor Commissioner’s determination.
35. Please list any witnesses who can support your Equal Pay Act claim. Name:
Title:
Address:
Witness Phone Number:
Witness Email Address:
Describe the information they have in connection to your complaint:
_________________________________________________________________________________________________________________________
Name:
Title:
Address:
Witness Phone Number:
Witness Email Address:
Describe the information they have in connection to your complaint:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Part 7: REMEDIES
Briefly describe what kind of remedy or solution you are seeking. What do you hope happens as a result of filing this complaint?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection.
Signed:
Date:
Print Name:
EPA-1 (August 2017)
(Continued, Page 3 of 3)

Download Form EPA-1 Equal Pay Act Complaint - California

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