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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
[Select one]
Carpenter
Roofer
Nailer
Mixer
Surface
(Need proper list here)
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?