Worker 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.

First and Last Name

Telephone

Email Address

Contractor/Subcontractor Name and License No. (if known)

Information you are reporting

Project Name

Location of project city (city and cross streets)

Is this a public works or government project? Please specify

First date you worked

Last date you worked

Total hours worked

Total hours paid for work

Hourly pay rate

How were you paid? Check? Cash? Or Both? Please specify

If paid by check, did you receive a check stub? Yes or no

Job Classification: Cement Mason, Journeyman, Apprentice, Other? Please specify

If you are an apprentice, are you registered for a formal apprenticeship training program? Yes or No

Your primary duty

Were you paid at least time-and-one-half for all hours worked in exess of 8 hours a day OR 40 hours per week? Yes or No

Were you ever threatened, intimidated or coersed into giving up any part of your wages? Yes or No

Would you like an LMCC investigator to contact you? Yes or No

Do you have any other comments and/or observations?