Complete this Form if you think you or someone else is treated as an independent contractor instead of an employee. Please provide us with as much information as you can. Language English Business Information This should be the owner and/or primary company representative. This area should NOT include your information. Legal Name of Business * First Name of Owner or Manager Last Name of Owner or Manager Business Primary Phone Number * Owner or Manager Phone Number Business Owner Email Address Business Address Address 1 * Address 2 City * State * AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * How many workers at the site? * Is the worksite active now? * - Select -YesNo Address and Worksite Location are the Same * Yes No Worksite Information Address 1 Address 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Work / Services Performed Do you perform services for this company? * Yes No Work Services Performed Details * Violation Information Please provide all relevant details. This is your statement regarding alleged violations. Describe what is going at this workplace. Tell us the facts. * Are workers classified as independent contractors? * Yes No How many workers are independent contractors? How are workers paid? * Cash Personal Check Payroll Check Combination Other If Paid Other Explain Do workers receive a pay stub? * Yes No Unknown Are the workers paid all wages owed? * Yes No Unknown Other Involved Parties Please enter name(s) and contact information Confidentiality Do you want this information to be kept confidential? * Iowa Workforce Development respects your privacy and will not disclose identifying information except as legally required. Yes No Contact Information This will allow us to follow up with you regarding the complaint in question. Your contact information is not required in order to file this complaint. First Name (Submitter) Last Name (Submitter) Primary Phone Number Secondary Phone Number Email Address Contact Address Information Address 1 Address 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Comments Comments Attachments Please .zip files if you need to include more than two documents. Files Upload More informationFiles must be less than 20 MB. Allowed file types: gif jpg jpeg png txt pdf doc xls xlsx zip. Files 2 Upload More informationFiles must be less than 20 MB. Allowed file types: gif jpg jpeg png txt pdf doc xls xlsx zip. Leave this field blank Submit Individual
