Form LLC-15 "Prevailing Wage Complaint" - Pennsylvania

What Is Form LLC-15?

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

Form Details:

  • Released on November 1, 2007;
  • The latest edition provided by the Pennsylvania Department of Labor & Industry;
  • 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 printable version of Form LLC-15 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Labor & Industry.

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Download Form LLC-15 "Prevailing Wage Complaint" - Pennsylvania

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prevailing wage complaint
This form is used for filing complaints under the Pennsylvania Prevailing Wage Act of 1961. Persons returning
this form should complete all parts, including the reverse side.
retUrn to:
Bureau of Labor Law Compliance
1301 Labor & Industry Building
Seventh & Forster Streets
Harrisburg, PA 17121
Telephone: 717-705-5969 or
1-800-932-0665
FAX: 717-787-0517
pleaSe print:
Name of Person Filing Complaint _____________________________________________________________________
Address _________________________________________________________________________________________
street
CItY
state
zIp Code
Date of Birth____________________________________________
telephone Number where you can be reached between 8:30 a.m. and 5:00 p.m. (______) ______ — _______________
(INClude area Code)
after 5:00 p.m. (______) ______ — _________________
Type of Work Performed ____________________________________________________________________________
Location of Employment_____________________________________________________________________________
street
CItY
CouNtY
state
zIp Code
Project Name and County Location _________________________________________________________________________
Name of employer (against whom the Wage Claim is filed) __________________________________________________
Company Name, if any __________________________________________ Telephone (______) ______— _______________
Address _________________________________________________________________________________________
street
CItY
CouNtY
state
zIp Code
date Hired _________________________________ are you still employed by the named employer?
Yes
No
If No, give the last date worked ___________________________ Was your termination:
Voluntary
Involuntary
1. Was there a written contract of employment between you and the named employer?
Yes
No
If Yes, please attach copy.
2. Were you notified by the named employer as to when and where you would be paid?
Yes
No
3. What was your regular payday to be? (check one)
Weekly
Bi-Weekly
Monthly
other ____________
4. Were wages paid to you in a form other than a check?
Yes
No
other (cash) _______________________
5. What was the latest rate of pay agreed upon between you and the named employer?
Hourly $_________ Weekly $_________ other, please explain _______________________________________________
What are the total wages claimed by you? $ ____________________________________________________________
complete reverSe Side
llC-15 REV 11-07 (Page 1)
CommoNwEalTh of PENNsylVaNia
DEPaRTmENT of laBoR & iNDusTRy
BuREau of laBoR law ComPliaNCE
prevailing wage complaint
This form is used for filing complaints under the Pennsylvania Prevailing Wage Act of 1961. Persons returning
this form should complete all parts, including the reverse side.
retUrn to:
Bureau of Labor Law Compliance
1301 Labor & Industry Building
Seventh & Forster Streets
Harrisburg, PA 17121
Telephone: 717-705-5969 or
1-800-932-0665
FAX: 717-787-0517
pleaSe print:
Name of Person Filing Complaint _____________________________________________________________________
Address _________________________________________________________________________________________
street
CItY
state
zIp Code
Date of Birth____________________________________________
telephone Number where you can be reached between 8:30 a.m. and 5:00 p.m. (______) ______ — _______________
(INClude area Code)
after 5:00 p.m. (______) ______ — _________________
Type of Work Performed ____________________________________________________________________________
Location of Employment_____________________________________________________________________________
street
CItY
CouNtY
state
zIp Code
Project Name and County Location _________________________________________________________________________
Name of employer (against whom the Wage Claim is filed) __________________________________________________
Company Name, if any __________________________________________ Telephone (______) ______— _______________
Address _________________________________________________________________________________________
street
CItY
CouNtY
state
zIp Code
date Hired _________________________________ are you still employed by the named employer?
Yes
No
If No, give the last date worked ___________________________ Was your termination:
Voluntary
Involuntary
1. Was there a written contract of employment between you and the named employer?
Yes
No
If Yes, please attach copy.
2. Were you notified by the named employer as to when and where you would be paid?
Yes
No
3. What was your regular payday to be? (check one)
Weekly
Bi-Weekly
Monthly
other ____________
4. Were wages paid to you in a form other than a check?
Yes
No
other (cash) _______________________
5. What was the latest rate of pay agreed upon between you and the named employer?
Hourly $_________ Weekly $_________ other, please explain _______________________________________________
What are the total wages claimed by you? $ ____________________________________________________________
complete reverSe Side
llC-15 REV 11-07 (Page 1)
CommoNwEalTh of PENNsylVaNia
DEPaRTmENT of laBoR & iNDusTRy
BuREau of laBoR law ComPliaNCE
Week
NuMBer of
gross Wages
speCIfY If
NuMBer of
rate of paY
eNdINg
ClassIfICatIoN
Hours Worked
daYs Worked
paId to You
VaCatIoN paY, sICk leaVe
per Hour, daY,
date
tHIs Week
for tHIs Week
or CoMMIssIoN
tHIs Week
Week or otHer
NOTE: Failure to provide detailed information in the space provided above may make it impossible to pursue this
claim on your behalf.
6. did the named employer refuse to pay these wages?
Yes
No
If Yes, the named employer’s reason for refusal ________________________________________________________
7. do you and the named employer agree as to the amount of wages due you?
Yes
No
If No, what amount does the named employer acknowledge as being due? $_________________________________
8. Has the named employer given you written confirmation of the amount due to you?
Yes
No
9. Has the named employer offered to pay you the amount to be due?
Yes
No
If Yes, have you accepted the amount offered?
Yes
No
10. Have you agreed in writing to any deductions?
Yes
No
If Yes, list deductions ____________________________________________________________________________
11. Have any deductions been made without your written agreement?
Yes
No
If Yes, please explain___________________________________________________________________________
12. do you owe any money to the named employer for any reason?
Yes
No
If Yes, how much? $________________
13. are you covered under a Collective Bargaining agreement?
Yes
No
If Yes, list the name and address of the union _________________________________________________________
You may use additional paper to summarize related information and wage computations.
NOTE: I hereby certify that to the best of my knowledge and belief, this is a true statement of facts relating to the
above claim of unpaid wages.
Signature of Claimant ________________________________________________ Date of Complaint _____________________
signature of parent or guardian if Claimant is under 18 years of age ______________________________________________
the Bureau will contact you for any further information. please notify the office listed on the other side of this form in
the event that you are paid before the Bureau contacts you.
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
llC-15
REV 11-07 (Page 2)
Page of 2