South Dakota > Workers Compensation
Wage Complaint - South Dakota
| Wage Complaint Form. This is a South Dakota form and can be used in Workers Compensation . |
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SOUTH DAKOTA DEPARTMENT OF LABOR DIVISION OF LABOR AND MANAGEMENT Kneip Building, Third Floor 700 Governors Drive Pierre, South Dakota 57501-2291 Telephone: 605-773-3682 WAGE COMPLAINT NAME OF EMPLOYEE: ___________________________________________________ HOME ADDRESS: _______________________________________________________ DATE OF BIRTH: _______________ SOCIAL SECURITY #: ________________ TELEPHONE #: HOME: (____)____________ OTHER: (____)____________ NAME OF EMPLOYER: (Owner/Partners/Corporation) ______________________________________________________________________ NAME OF BUSNESS: (As listed in telephone or other directory) ______________________________________________________________________ ADDRESS OF BUSINESS: ________________________________________________ TELEPHONE #: (____)___________ IS BUSINESS STILL IN OPERATION? YES_____ NO____ IF NO, DATE BUSINESS CEACED OPERATION: ______________________________ IS BUSINESS IN BANKRUPTCY? YES_____ NO____ HAS BUSINESS FILED OR COMPLETED BANKRUPTCY? YES_____ NO____ IS OWNER IN BANKRUPTCY? YES_____ NO____ HAS OWNER FILED OR COMPLE TED BANKRUPTCY? YES_____ NO____ IF ANSWER YES TO THE ABOVE QUESTIONS, PLEASE INDICATE DATE AND LOCATION OF BANKRUPTCY:_________________________________________________________ DATE OF HIRE: _____________________________ ARE YOU STILL EMPL THIS BUSINESS? OYED WITH YES_____ NO____ IF NO, DATE OF TERMINATION:________________ DID YOU: VOLUNTARILY TERMINATE___________ TERMINATED BY EMPLOYER_________ LAID OFF__________ DID ANY WRITTEN CONTRACT OF AGREEMENT EXIST BETWEEN YOU AND THE NAMED EMPLOYER? YES_____ NO____ (If yes, please attach a copy) WHAT DID EMPLOYER AGREE TO PAY UPON HIRING: $_______ HOUR $_______ MONTH $_______ YEAR (Please complete second page also.) PAY DAYS WERE: <<<<<<<<<********>>>>>>>>>>>>> 2WEEKLY_______ BI-MONTHY_______ MONTHLY_______ OTHER_______ IF OTHER, PLEASE EXPLAIN: _______________________________________ RATE OF PAY AT THE TIME OF TERMINATION: $_______ HOUR $_______ MONTH $_______ YEAR WAS THERE EVER A SPECIFIC WRITTEN RATE OF PAY AGREEMENT? YES____ NO_____ (if yes, please attach a copy) TOTAL AMOUNT OF WAGES, SALARY, ECT. DUE $____________________________ HOW THIS AMOUNT WAS CALCULATED: (Attach any supporting documents i.e timecards, paystubs, ect.)____________________________________________________________ ________________________________________________________________________ ____ ________ DATE PAYMENT WAS REQUEST ED FROM EMPLOYER: ___________________ WAS THIS REQUEST IN WRITING: YES____ NO____ DO YOU OWE EMPLOYER FOR GOODS OR SERVICES PURCHASED, OR CASH ADVANCES? YES_____ NO____ AMOUNT OWED: $__________ REPAYMENT PLAN: __________________________________________________ DO YOU HAVE ANY PROPERTY OF THE EMPLOYER IN YOUR POSESSION? YES____ NO____ PLEASE LIST ADDITIONAL DETAILS OR EXPLANATION AND SUPPORTING DOCUMENTS. USE ADDITIONAL SHEET IF NECESSARY. ________________________________________________________________________ ____ ________________________________________________________________________ ____ ________________________________________________________________________ ____ The information furnished is confidential and will be used only by the Division of Labor and Management for the purpose of investigation of this matter. ANY EMPLOYEE WHO SHALL FALSIFY THE AMOUNT DUE HIMSELF OR WHO INTENTIONALLY ATTEMPTS TO DEFRAUD THE EMPLOYER HAS COMMITED A CLASS 2 MISDEMEANOR. If this matter is resolved in whole or in part at any time, please notify this office immediately at (605) 773-3682. ________________________________ S IGNATURE D ATE DOL-LM-8/02
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