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Suspected Fraud Report Form

Submit this form ONLY if you are a WORKER.
Thank you for your comments and/or observations regarding a specific project or contractor. Personal information will never be devulged to anyone without your expressed written permission.
Your personal Information: (Remember, your identity is PROTECTED!)
Your Name (required)
Telephone (required)
Email (required)
Information you are reporting:
Contractor/Subcontractor Name  
License No. (if known)
Project name
Location of project
Is this a public works or
government project?		 Yes     No
First date you worked
Last date you worked
Total hours worked
Total hours paid for
Hourly pay rate
How were you paid?
Paid by check     Paid by cash     Both

If you were paid by check, did you receive a check stub?
 Yes     No
Job classification
Journeyman/Apprentice
Journeyman     Apprentice

If you are an apprentice, are you registered for a
formal apprenticeship training program?
 Yes     No
Your primary duty?
Were you paid at least
time-and-one-half for
all hours worked in excess
of 8 hours a day OR 40 hours per week?		 Yes     No
Were you ever threatened,
intimidated or cohersed
into giving up any part
of your wages?		 Yes     No
Would you like and investigator to contact you? Yes     No
Do you have any other
comments and/or
observations?