"Prevailing Wage Complaint Form" - Minnesota

Prevailing Wage Complaint Form is a legal document that was released by the Minnesota Department of Transportation - a government authority operating within Minnesota.

Form Details:

  • Released on October 1, 2009;
  • The latest edition currently provided by the Minnesota Department of Transportation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Minnesota Department of Transportation.

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Minnesota Department of Transportation
Labor Compliance Unit
Mail Stop 650
395 John Ireland Blvd.
St. Paul, MN 55155-1899
Prevailing Wage Complaint Form
Phone: (651) 366-4204
Fax: (651) 366-4248
www.dot.state.mn.us/const/labor
Print in INK or TYPE your responses. An incomplete form
Please provide as much information as possible. If you don’t have a response, mark
or one that is not signed may be returned or denied.
“unknown” in the space provided; estimated responses are acceptable.
CLAIMANT INFORMATION
NAME
HOME TELEPHONE
STREET ADDRESS
WORK TELEPHONE
CITY
STATE
ZIP CODE
CELL TELEPHONE
E-MAIL ADDRESS
OTHER TELEPHONE
PROJECT INFORMATION
STATE PROJECT NUMBER
PROJECT LOCATION (ROAD NUMBER & COUNTY AND/OR CITY)
PRIME/GENERAL CONTRACTOR NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE
TYPE OF CONSTRUCTION:
IS THE PROJECT COMPLETE?
Road
Bridge
Building
Trail
Airport
Tower
Other ______________
Yes
No
Unknown
EMPLOYER INFORMATION
NAME
Are you still employed by this employer?
Yes
No
ADDRESS
TELEPHONE
If NO, last date worked:
CITY
STATE
ZIP CODE
Was your termination?
Voluntary
Involuntary
WAGE AND HOUR INFORMATION
Type of work performed on the project:
Nature of complaint (more than one may apply):
Wage Rate
Overtime
Fringes
Classification
Dates worked on this project:
Total hours worked on this project:
How often were you paid?
From:
To:
Regular:
Overtime:
Weekly
Monthly
Bi-weekly
Other____________
Regular hourly rate of pay:
Overtime hourly rate of pay:
Did you work on a shift schedule?
This project
Non-project work
This project
Non-project work
Yes
No
If, Yes, which shift?
Day
Night
Were you paid overtime at 1 1/2 times your hourly rate of pay
Were you an apprentice?
If an apprentice, which trade?
after:
8 hrs/day?
Yes
No
40 hrs/wk?
Yes
No
Yes
No
How were you paid?
Hours worked recorded by:
Recorded by foreman
Check
Check and Cash
Cash
Other
Time card/sheet
Called into office
Other ____________
Did you receive fringe benefits?
Yes
No If Yes, select: Did you receive cash payment for fringes?
Yes
No
Health Insurance
Training
Vacation
Life
If yes, how much per hour?
I
Sick Leave
Holidays
Pension
Other
Has money been advanced to you by your employer?
Did you receive transportation, board and/or lodging expenses?
Yes
No If Yes, how much?
Yes
No How much?
hour /
day
(10/2009)
(over)
Minnesota Department of Transportation
Labor Compliance Unit
Mail Stop 650
395 John Ireland Blvd.
St. Paul, MN 55155-1899
Prevailing Wage Complaint Form
Phone: (651) 366-4204
Fax: (651) 366-4248
www.dot.state.mn.us/const/labor
Print in INK or TYPE your responses. An incomplete form
Please provide as much information as possible. If you don’t have a response, mark
or one that is not signed may be returned or denied.
“unknown” in the space provided; estimated responses are acceptable.
CLAIMANT INFORMATION
NAME
HOME TELEPHONE
STREET ADDRESS
WORK TELEPHONE
CITY
STATE
ZIP CODE
CELL TELEPHONE
E-MAIL ADDRESS
OTHER TELEPHONE
PROJECT INFORMATION
STATE PROJECT NUMBER
PROJECT LOCATION (ROAD NUMBER & COUNTY AND/OR CITY)
PRIME/GENERAL CONTRACTOR NAME
STREET ADDRESS
CITY
STATE
ZIP CODE
TELEPHONE
TYPE OF CONSTRUCTION:
IS THE PROJECT COMPLETE?
Road
Bridge
Building
Trail
Airport
Tower
Other ______________
Yes
No
Unknown
EMPLOYER INFORMATION
NAME
Are you still employed by this employer?
Yes
No
ADDRESS
TELEPHONE
If NO, last date worked:
CITY
STATE
ZIP CODE
Was your termination?
Voluntary
Involuntary
WAGE AND HOUR INFORMATION
Type of work performed on the project:
Nature of complaint (more than one may apply):
Wage Rate
Overtime
Fringes
Classification
Dates worked on this project:
Total hours worked on this project:
How often were you paid?
From:
To:
Regular:
Overtime:
Weekly
Monthly
Bi-weekly
Other____________
Regular hourly rate of pay:
Overtime hourly rate of pay:
Did you work on a shift schedule?
This project
Non-project work
This project
Non-project work
Yes
No
If, Yes, which shift?
Day
Night
Were you paid overtime at 1 1/2 times your hourly rate of pay
Were you an apprentice?
If an apprentice, which trade?
after:
8 hrs/day?
Yes
No
40 hrs/wk?
Yes
No
Yes
No
How were you paid?
Hours worked recorded by:
Recorded by foreman
Check
Check and Cash
Cash
Other
Time card/sheet
Called into office
Other ____________
Did you receive fringe benefits?
Yes
No If Yes, select: Did you receive cash payment for fringes?
Yes
No
Health Insurance
Training
Vacation
Life
If yes, how much per hour?
I
Sick Leave
Holidays
Pension
Other
Has money been advanced to you by your employer?
Did you receive transportation, board and/or lodging expenses?
Yes
No If Yes, how much?
Yes
No How much?
hour /
day
(10/2009)
(over)
WORK PERFORMED
Primary Work Classification/Title:
Did you operate equipment?
Yes
No If Yes, what type?
Did you drive truck?
Type of Truck
Truck or License Plate #
Yes
No If Yes, what type of truck & truck or license plate number?
Did you work at or haul from an off-site material operation?
Pit Name and Location
Type of Material Hauled
Yes
No If Yes, provide pit name, location & material hauled.
Did you seed, sod or plant trees and bushes?
Yes
No
Did you work more than 8 feet underground?
Yes
No
PLEASE DESCRIBE WORK DUITES AND TOOLS/EQUIPMENT USED
Duties
Tools/Equipment Used
Are there any inspectors, co-workers or supervisors that can verify your work on the project? Please include name and telephone number:
Additional comments:
If necessary, does Mn/DOT have permission to use your name to resolve this matter?
Yes
No
To the best of my knowledge, the information that I’ve provided is true and accurate.
COMPLAINANT SIGNATURE
DATE
In order to substantiate your claim, please submit “COPIES” of some or all of the following records:
- Daily Journals
- Detailed Earning Statements / Check Stubs
- Log Books
- Original or Canceled Payroll Checks
- Haul Slips
- Daily or Weekly Time Cards
If your complaint involves more than one project,
please attach a separate
sheet. Additionally, please make a COPY
of this complaint for your records and submit the original, along with COPIES of supporting documentation to:
Minnesota Department of Transportation
ATTENTION: PW Complaints
Labor Compliance Unit
Mail Stop 650
395 John Ireland Blvd.
St. Paul, MN 55155-1899
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