"Complaint Form for Freelance Workers" - New York City

Complaint Form for Freelance Workers is a legal document that was released by the New York City Department of Consumer Affairs - a government authority operating within New York City.

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COMPLAINT FORM FOR FREELANCE WORKERS
Thank you for contacting the Office of Labor Policy & Standards (OLPS) within the New York City Department of Consumer Affairs (DCA).
Clearly print or type your answers to each question. If a question does not apply to you, please mark N/A or Not Applicable.
If you have any questions about this form or would prefer to have a staff member help you complete the form, please contact DCA at
Freelancer@dca.nyc.gov, call (212) 436-0380, or visit OLPS at the address below. If you need or prefer to use a language other than English,
we can provide free translation assistance. You can submit the completed form in the following ways:
Email:
Freelancer@dca.nyc.gov
OR
Mail or hand deliver to: New York City Department of Consumer Affairs, Attn: Office of Labor Policy & Standards,
42 Broadway, 9th Floor, New York, NY 10004
After OLPS receives your completed form, we will contact you to gather any additional information we need or to notify you what action we will
be taking.
FREELANCE WORKER INFORMATION
First Name
M.I.
Last Name
Primary Language Used
Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Borough
Phone Number 1 (Primary)
Phone Number 2 (Secondary)
Email Address
Business Name (if applicable)
Occupation
Architecture/
Construction
Education
Food/Dining
Industrial/
Journalism/
Industry:
Design
Manufacturing
Publishing
Other
Marketing
Nonprofit
Other Media
Retail or
Transportation
_________________________
Fashion
Have you retained an attorney to represent you in this matter?
If Yes, please provide name and contact information.
Yes
No
By providing your email address, you consent to receive communications electronically from the Department of Consumer Affairs (DCA), and you
affirm that the email listed is a reliable form of communication for you.
HIRING PARTY INFORMATION
Is Hiring Party an Individual or a Business?
Individual
Business
Other (specify):
Name
Primary Contact
Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Phone Number
AGREEMENT BETWEEN YOU AND THE HIRING PARTY
1. Briefly describe the work you were contracted to perform.
2. What was the
3. What is the total
4. How much has the
approximate value of
amount owed to you?
Hiring Party paid you
$
$
$
the contract?
to date?
5. On what date did you reach agreement with the Hiring Party?
/
/
(MM/DD/YY)
6. Did you and the Hiring Party sign a written contract?
I don’t know
No
Yes
(If Yes, attach it to this form.)
7. Did you ask the Hiring Party to execute a written contract detailing the
Yes
No
work agreement and they refused?
8. If there was no written agreement, how did the Hiring Party
Orally
Email
Through third party
communicate the payment amount for the work?
9. How much did the Hiring Party agree to pay you?
$
(Please describe the total amount or, if applicable, the pay rate.)
COMPLAINT FORM FOR FREELANCE WORKERS
Thank you for contacting the Office of Labor Policy & Standards (OLPS) within the New York City Department of Consumer Affairs (DCA).
Clearly print or type your answers to each question. If a question does not apply to you, please mark N/A or Not Applicable.
If you have any questions about this form or would prefer to have a staff member help you complete the form, please contact DCA at
Freelancer@dca.nyc.gov, call (212) 436-0380, or visit OLPS at the address below. If you need or prefer to use a language other than English,
we can provide free translation assistance. You can submit the completed form in the following ways:
Email:
Freelancer@dca.nyc.gov
OR
Mail or hand deliver to: New York City Department of Consumer Affairs, Attn: Office of Labor Policy & Standards,
42 Broadway, 9th Floor, New York, NY 10004
After OLPS receives your completed form, we will contact you to gather any additional information we need or to notify you what action we will
be taking.
FREELANCE WORKER INFORMATION
First Name
M.I.
Last Name
Primary Language Used
Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Borough
Phone Number 1 (Primary)
Phone Number 2 (Secondary)
Email Address
Business Name (if applicable)
Occupation
Architecture/
Construction
Education
Food/Dining
Industrial/
Journalism/
Industry:
Design
Manufacturing
Publishing
Other
Marketing
Nonprofit
Other Media
Retail or
Transportation
_________________________
Fashion
Have you retained an attorney to represent you in this matter?
If Yes, please provide name and contact information.
Yes
No
By providing your email address, you consent to receive communications electronically from the Department of Consumer Affairs (DCA), and you
affirm that the email listed is a reliable form of communication for you.
HIRING PARTY INFORMATION
Is Hiring Party an Individual or a Business?
Individual
Business
Other (specify):
Name
Primary Contact
Address (Building Number, Street Name, Apartment/Suite/Other)
City
State
ZIP Code
Phone Number
AGREEMENT BETWEEN YOU AND THE HIRING PARTY
1. Briefly describe the work you were contracted to perform.
2. What was the
3. What is the total
4. How much has the
approximate value of
amount owed to you?
Hiring Party paid you
$
$
$
the contract?
to date?
5. On what date did you reach agreement with the Hiring Party?
/
/
(MM/DD/YY)
6. Did you and the Hiring Party sign a written contract?
I don’t know
No
Yes
(If Yes, attach it to this form.)
7. Did you ask the Hiring Party to execute a written contract detailing the
Yes
No
work agreement and they refused?
8. If there was no written agreement, how did the Hiring Party
Orally
Email
Through third party
communicate the payment amount for the work?
9. How much did the Hiring Party agree to pay you?
$
(Please describe the total amount or, if applicable, the pay rate.)
10. If you completed the work under the contract, on what date did you
/
/
(MM/DD/YY)
complete the work?
11. According to your agreement, when should the Hiring Party have paid
/
/
(MM/DD/YY)
you?
ADDITIONAL QUESTIONS
1. Were you hired to perform work for a local, state, or federal
Yes
No
government entity?
2. Were you hired to provide legal services?
Yes
No
3. Did the work you were hired to do include acting as a sales
Yes
No
representative for the Hiring Party?
4. Are you a licensed medical professional?
Yes
No
5. Were you hired to do the work individually or as part of a group of two
Individually
Group of 2 or more
or more people?
6. Have you attempted to collect payment by initiating a court or
Yes
No
administrative action?
If Yes, please provide the name, date, status, and case number:
7. Please indicate which of the following are relevant to your complaint. Check all that apply.
Not paying you on or before the date(s)
Refusing to provide a written contract
Retaliating against you for exercising your
agreed to or within 30 days of finishing the
detailing the work agreement
rights under the Freelance Isn’t Free Act
work
(retaliation may include preventing you from
obtaining future work opportunities)
Refusing to include required terms in a
In order to be paid on time, asking you to
Other (please specify):
written contract
accept less than the agreed-upon payment
after you started the work
8. In your own words, please describe your complaint against the Hiring Party. Use additional sheets, if necessary.
9. Please provide us with any additional information relevant to your complaint.
Please provide any relevant documents along with this form. This includes any written invoices or contracts, correspondence related to the
terms of your payment, evidence showing previous attempts you have made to collect payment for the work performed, or copies of any
civil or administrative complaints filed by you or the Hiring Party about the contract that is the subject of this complaint.
I affirm that to the best of my knowledge, this information is true, correct, and complete.
____________________________________________
____________________________________________
Signature of Freelance Worker filing complaint
Date
____________________________________________
Print Name
If the Freelance Worker is under 18 years of age, please provide the following information:
____________________________________________
____________________________________________
Name of Parent or Guardian (please print)
Date
____________________________________________
Signature of Parent or Guardian
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