Form MDT-CON-004 "Prevailing Wage Complaint" - Montana

What Is Form MDT-CON-004?

This is a legal form that was released by the Montana Department of Transportation - a government authority operating within Montana. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2021;
  • The latest edition provided by the Montana Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MDT-CON-004 by clicking the link below or browse more documents and templates provided by the Montana Department of Transportation.

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Download Form MDT-CON-004 "Prevailing Wage Complaint" - Montana

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Submit to:
Kathy Terrio
Montana Department of Transportation
MDT - CAS Bureau
2701 Prospect Ave
Prevailing Wage Complaint
PO Box 201001
MDT-CON-004
Rev. 01/2021
Helena MT, 59620-1001
Page 1 of 2
kterrio@mt.gov
This is a fillable PDF form. Please type your responses in the form field prior to printing. Some fields are hidden, depending on
your response to the questions. Provide as much information as possible to better assist you.
Project Description:
Prime Contractor:
Fed/State Project Number:
Project Manager:
Contract ID:
Type of Construction:
Is the project complete? Yes
No
Unknown
Claimant Information
Name:
Home Phone:
Work Phone:
Mailing Address:
Employer Information
Name of Contractor employed by:
Phone No. :
Address:
Name of immediate supervisor:
Are you still employed by this employer? Yes
No
Nature of Complaint:
Type of work performed (check all that are applicable):
Laborer
Operator
Truck driver
Concrete
Ironworker
Carpenter
Other
Wage Information
Dates worked on this project: From:
To:
Estimated
Total hours worked on this project:
Regular:
Overtime:
responses are
Regular hourly rate of pay:
This project:
Non-project work:
acceptable. If
question does not
Overtime hourly rate of pay:
This project:
Non-project work:
apply, leave blank.
Were you paid overtime at 1-1/2 times your hourly rate of pay after 40 hrs./wk.? Yes
No
Hours worked recorded by:
Were you an apprentice? Yes
No
How often were you paid?
How were you paid?
Did you receive fringe benefits? Yes
No
Did you receive cash payment for fringes? Yes
No
Has money been advanced to you by your employer? Yes
No
Did you receive transportation, board and/or lodging expenses? Yes
No
Submit to:
Kathy Terrio
Montana Department of Transportation
MDT - CAS Bureau
2701 Prospect Ave
Prevailing Wage Complaint
PO Box 201001
MDT-CON-004
Rev. 01/2021
Helena MT, 59620-1001
Page 1 of 2
kterrio@mt.gov
This is a fillable PDF form. Please type your responses in the form field prior to printing. Some fields are hidden, depending on
your response to the questions. Provide as much information as possible to better assist you.
Project Description:
Prime Contractor:
Fed/State Project Number:
Project Manager:
Contract ID:
Type of Construction:
Is the project complete? Yes
No
Unknown
Claimant Information
Name:
Home Phone:
Work Phone:
Mailing Address:
Employer Information
Name of Contractor employed by:
Phone No. :
Address:
Name of immediate supervisor:
Are you still employed by this employer? Yes
No
Nature of Complaint:
Type of work performed (check all that are applicable):
Laborer
Operator
Truck driver
Concrete
Ironworker
Carpenter
Other
Wage Information
Dates worked on this project: From:
To:
Estimated
Total hours worked on this project:
Regular:
Overtime:
responses are
Regular hourly rate of pay:
This project:
Non-project work:
acceptable. If
question does not
Overtime hourly rate of pay:
This project:
Non-project work:
apply, leave blank.
Were you paid overtime at 1-1/2 times your hourly rate of pay after 40 hrs./wk.? Yes
No
Hours worked recorded by:
Were you an apprentice? Yes
No
How often were you paid?
How were you paid?
Did you receive fringe benefits? Yes
No
Did you receive cash payment for fringes? Yes
No
Has money been advanced to you by your employer? Yes
No
Did you receive transportation, board and/or lodging expenses? Yes
No
Submit to:
Kathy Terrio
Montana Department of Transportation
MDT - CAS Bureau
2701 Prospect Ave
Prevailing Wage Complaint
PO Box 201001
MDT-CON-004
Rev. 01/2021
Helena MT, 59620-1001
Page 2 of 2
kterrio@mt.gov
Primary Work Classification/Title:
Did you operate equipment? Yes
No
Did you work at or haul from an off-site material operation? Yes
No
Describe Work Duties 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 names
and telephone numbers.
Additional Comments:
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
Date
Signature
I hereby authorize the Montana Department of Transportation to release my name to
during their investigation of my labor complaint on the above project.
Page of 2