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RETALIATION AND/OR EQUAL PAY ACT (EPA) COMPLAINT

For information about filing Retaliation and EPA complaints visit: dir.ca.gov/dlse/dlseRetaliation.html.
File Retaliation Complaints and Equal Pay Act Complaints separately.

Complaint Type

What type of complaint are you filing?

Claimant Information

First Name

Middle name

Last Name

Street Address

City

State

Zip Code

Date of Birth (MM/DD/YYYY)

Phone

Language Assistance

Do you need an interpreter?

Interpreter language

Advocate/Representative assistance

Are you being assisted by a lawyer or other advocate?

Representation/Advocate Information

Representation/Advocate Type

Business Name

First Name

Last Name

Street Address

City

State

Zip Code

Phone

Employer/Business Information

Employer/Business Type

Employer Business Name

Employer First Name

Employer Last Name

Street Address

City

State

Zip Code

Phone

Name of Person in Charge

Job Title/Position of Person in Charge

Type of work performed

Total number of employees

Employer still in business?

Other work location

Is the address where you worked different from the business address provided?

Add work address for claimant

Street Address

City

State

Zip Code

Employment Status

Still Working for Employer?

Date of hire (MM/DD/YYYY)

If you are no longer working for the employer, what was your final rate of pay?

Please specify if paid by hour, day, week, month, piece rate, commission or a combination.

Last job title with Employer

Complete at least one of the following

Quit Date (MM/DD/YYYY)

Discharged Date (MM/DD/YYYY)

Suspended Date (MM/DD/YYYY)

Other

Immigration Threat

Did your employer make immigration threats?

Please explain:

Other Claims Filed

Have you filed a claim for unpaid wages against your employer with the Labor Commissioner’s Office?

If you were not paid your wages and would like to learn about filing a wage claim, please visit: https://www.dir.ca.gov/dlse/HowToFileWageClaim.htm

Other Claim Information

When did you file your wage claim (MM/DD/YYYY)

How did you file your wage claim

Case number

What was the issue claimed?

Retaliation

Why did you file this complaint?

Date the change to your employment occurred (MM/DD/YYYY)

Please describe what happened

Names of persons carrying out changes to your employment

Enter the name(s) of each person involved in carrying out changes. Separate each name with a semi-colon (;).

Titles of persons carrying out changes to your employment

Enter the title(s) of each person involved in carrying out changes. Separate each name with a semi-colon (;).

What reason would the employer give for the changes to your employment that you selected from the list above and described?

What right did you exercise or action did you take that lead to your change in employment?

Describe how your employer knew about the right you exercised or the action(s) you took?

Are other employees also filing retailation claims against your employer?

Have you filed or do you plan to file a separate EPA (Equal pay Act) complaint?

Equal Pay Act (EPA)

Do you claim you were paid less than an employee of the opposite sex or of a different race who is performing substantially similar work?

What is the basis of the claim?

What is your sex, race/ethnicity?

What is your job title and/or occupation?

What are your job duties?

How much are you paid? Include all your compensation: wages, bonuses, commissions, other.

What are the name(s), job position(s), job duties, and location of the other employee(s) who are being paid more?

What is the sex or race/ethnicity of your co-worker(s)?

How much is your co-worker(s) paid? Include all of this employee’s compensation.

Please include any other information relevant to your claim that you were paid less than another employee of the opposite sex or other race who is performing substantially similar work.

Have you asked your employer why you are paid less than your co-worker? If yes, what was your employer’s response?

Are the reasons that your employer gave untrue? Please explain.

Do you believe that you have also been retaliated against because you exercised your rights under the Equal Pay Act? If so, submit a separate Retaliation Complaint.

Witnesses

Do you have witnesses to the workplace events described above?

All witnesses are confidential, and the Labor Commissioner’s Office will not reveal their identiies unless it becomes necessary to proceed with the investigation or to enforce the Labor Commissioner’s determination.

Add Witness

First Name

Last Name

Job Title

Street Address

City

State

Zip Code

Phone

Please provide a brief explanation of what they saw/heard related to your complaint

Remedies

Briefly describe what you hope happens as a result of filing the complaint.

Authorizations to Release Information

By submitting this form, I hereby certify that the information I have provided is true to the best of my knowledge and/or recollection, and I further acknowledge that this information is being collected by the State and may be shared with another state agency or a private party in accordance with California Civil Code section 1798.24 and the Information Practices Act of 1977 generally. For more information regarding the Department of Industrial Relation’s Privacy Policy, please go to www.dir.ca.gov/od_pub/privacy.html

Please click the ‘Submit’ button to review your responses on the summary page. You may print a copy for your records from the summary page. However, to complete the process, you must click the ‘Confirm’ button for the data to be received by the Labor Commissioner’s Office. If you do not click the Submit and Confirm buttons, your claim will not be filed and you may miss your deadline to file with the Labor Commissioner’s Office.

Please only click the 'Submit/Confirm' button once. Please do not close this window or click the Back button on your browser after clicking 'Submit/Confirm' until the submission process has completed.

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