Fill and Sign the Hearing Aid Purchase Agreement Form

BEFORE FILING A WAGE CLAIM, PLEASE READ THESE INSTRUCTIONS CAREFULLY! Do Not Fill Out The Prevailing Wage Complaint Form If: • You acted as an "independent contractor" and not as an "employee" of the business. • You are self-employed or an owner/operator. • You have filed suit against your employer for the same wage or fringe benefit claim. • You already have a civil court judgment involving this claim. • You are trying to obtain a W-2 or 1099. If so , you should contact the Internal Revenue Service at 1-800-829-1040. • Your employer has filed bankruptcy or has been determined bankrupt. If so, you will need to contact the Bankruptcy Court for further instructions. • You do not know your employer’s address or location. • You intend to file against more than one business. Use a separate wage claim form for each business against whom you wish to file a claim. Also, each claimant intending to file against an employer must use a separate claim form. • The statute of limitation s for your claim has expired. A 3-year statute of limitations applies when filing a complaint for prevailing wages. FILING A WAGE CLAIM IF CLAIM FORM IS NOT COMPLE TED AS INDICATED IN THESE I NSTRUCTIONS IT MAY BE RETURNED TO YOU. Fill out the claim form Read all questions on the claim form carefully before answering. completely, legibly and accurately, providing as much of the requested information as possible. In order for your claim to be processed the following information must be provided: • Name and address of the complainant. • Provide a telephone nu mber where you may be reached during the day. If your address or telephone number changes, it is your responsibility to notify the Department immediately or your claim may be closed. • Name and address of contractor alleged to have committed the violation. Your claim will be returned if a complete address is not provided. • Contracting agent name and address, project name and description, location where the work was performed; and construction dates. WHD-943B • Description of the complaint. • Identify classification of each construction mechanic alleged to be underpaid. • Attach copies of any documents that you have, which support your claim such as an employment contract, time records, check stubs, fringe benefit policies, etc. A wage claim may be fi led in person from 8 a.m. to 5 p.m., Monday through Friday, at 7150 Harris Drive, Dimondale, MI 48821 or by mailing to: Department of Licensing and Regulatory Affairs Wage & Hour Division PO Box 30476 Lansing, Michigan 48909-7976 When the Wage & Hour Division receives your claim form the following steps are taken: 1. The claim form is given to an investigator to review. The investigator determines if all of the required information is on the claim form and whether investigation of the claim is within the division’s authority. 2. The claim is then opened and a notification letter sent by the division to the employer requesting a written re sponse within 14 workin g days. The letter requests documentation regarding the claim that has been filed and/or a check for any portion of the claim not disputed. Any monies received will be forwarded to you. You do not need to contact the Wage & Hour Division to receive payment. 3. All investigators work on a first-in, first-out basis. This means that you will not be contacted by the inves tigator assigned to your claim until the claim co mes up in rotation on his/her caseload. This may take a while . An investigation usu ally begins 30-60 days after a complaint is received. The time required to complete an investigation depends on the cooperation of the parties involved, and the complexity of the claim. In the interim, you should obtain whatever records or documentation you have to support your claim and have it available when the investigator contacts you. 4. It is important that you notify the Wage & Hour Division of any change in your address or daytime phone number. Failure to report this information will delay the investigation of your complaint. In addition, the division cannot mail any monies received without a current address. By filing this claim with the Wage & Hour Division, you are electing a remedy which may prevent you from pursuing this claim elsewhere, including civil court. WHD-943B Claim Number: PREVAILING WAGE COMPLAINT Michigan Department Licensing and Regulatory Affairs Michigan Occupational Safety & Health Administration Wage & Hour Division Mailing Address: Street Address: P.O. Box 30476 7150 Harris Drive Lansing, MI 48909-7976 Dimondale, MI 48821 Telephone: 517.322.1825 Facsimile: 517.322.6352 Website: www.michigan.gov/wagehour LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available, upon request, to individuals with disabilities. Please call 517.322.1825 to make your needs known to this agency. AUTHORITY: COMPLETION: PENALTY: PUBLIC ACT 166 OF 1965, AS AMENDED VOLUNTARY NONE Attach with complaint sufficient evidence to support your allegation (i.e., payroll records, project's prevailing wage rates, pay stubs, etc.) COMPLAINANT INFORMATION Complete only one section: A or B. A=Individual B=Third Party A. EMPLOYEE NAME: (if filing as an individual) B. NAME: (if filing as a third party) LAST FOUR DIGITS OF SOCIAL SECURITY #: (if filing as ORGANIZATION YOU REPRESENT: (if filing as a third party) an individual) DATE OF BIRTH: (if filing as an individual) ADDRESS (if you completed Section A, use individual's address; if you completed Section B, use organization's address) CITY, STATE, ZIP: TELEPHONE NUMBER WHERE YOU CAN BE CONTACTED BETWEEN 8:00 A.M. AND 5:00 P.M., MONDAY THRU FRIDAY: COUNTY: EMPLOYER INFORMATION CONTRACTOR/SUBCONTRACTOR NAME: ADDRESS: CITY, STATE, ZIP: COUNTY: TELEPHONE NUMBER: PROJECT INFORMATION CONTRACTING AGENT (i.e., school, state agency, university, etc.): CONTRACTING AGENT ADDRESS: CITY, STATE, ZIP: TELEPHONE NUMBER: PROJECT NAME: PROJECT DESCRIPTION: PROJECT LOCATION (STREET ADDRESS, CITY, COUNTY, STATE and ZIP): DATES WORKED ON THE PROJECT: EMPLOYEE JOB CLASSIFICATION(S) (i.e.,: IS EMPLOYEE AN APPRENTICE? carpenter, plumber, electrician, etc.) Yes No IF YES, APPROXIMATELY HOW MANY APPRENTICES ON SITE? WHD-943B (02/12) PLEASE COMPLETE THE REVERSE SIDE OF THIS FORM Page 1 PREVAILING WAGE COMPLAINT ALLEGATION OF COMPLAINT ATTACH WITH COMPLAINT SUFFICIENT EVIDENCE TO SUPPORT YOUR ALLEGATION (I.E., PAYROLL RECORDS, PROJECT'S PREVAILING WAGE RATES, PAY STUBS, ETC.) DESCRIBE THE COMPLAINT – Include in detail the tasks performed on this project and identify the working title of the job classification. How did you determine the contractor was in violation of the prevailing wage law? What was the specific job title of the employee(s)? Please describe in detail the specific job duties the employee(s) was required to perform. Did the employee(s) supervise others? Yes No Who is the direct supervisor of the employee(s)? What was the hourly rate of pay for the employee(s)? Start date of employment: End date of employment: Check any fringe benefits the employer provided: health & welfare contributions pension or retirement contributions profit sharing distribution annuity fund or tax deferred savings plan contributions supplemental employment fund contributions education or training fund contributions vacation pay medical insurance life insurance holiday pay bonus scholarship contributions Any additional information you wish to add: Page 2