Intake Complaint Form Submitted by dlfaison on Mon, 04/06/2026 - 16:54 Please complete all of the required fields. Name of Company or Individual you suspect is committing misclassification Business address or address of individual Business Address Suite or building # City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP/Postal Code Business Phone Number Approximate number of employees (this includes both 1099 and W-2 workers) Employee Working relationship Nature of work activities being performed How many additional workers perform the same and/or similar duties? Does the company inform you when to arrive/leave work? Yes No Does the company provide direction on how to complete specific tasks? Yes No Does the company provide equipment to complete tasks? Yes No Does the company provide uniforms, or attire with a company logo? Yes No Does the company pay by the job, hourly, weekly, monthly or commission? Pay by the job Hourly Weekly Monthly Commission Can you provide documentation that supports the claim for misclassification, including but not limited to: tax documentation, copies of payment records, employment offer letter, or documentation pertaining to agreement for contracted services? Yes No Email Address Please enter your email address to receive a copy of your submission information. Phone Number
