Complaint Inquiry

Instructions

The Complaint Inquiry form is used to report to the North Dakota Department of Labor and Human Rights (Department) that a state law is being violated relative to laws such as final paycheck, breaks, paystubs, youth employment, etc. The Complaint Inquiry process is an informal process. After receiving the completed form, the Department will contact the employer by letter, telephone, or email. The Department will discuss the nature of the concern and advise the employer of the legal requirements related to the issue.

The Complaint Inquiry form should be completed either by someone directly affected by the situation or someone who has directly witnessed the situation. Please complete all items on the form. No action will be taken on incomplete or unsigned forms. Once your complaint is accepted, your cooperation is required. Your failure to cooperate will result in the dismissal of your complaint.

The Department will address your complaint as quickly as possible in the order in which it is received.

Note: Fields marked with an asterisk (*) are required.

I certify that I have read these instructions and understand my rights and duties.*

Yes No

STOP: You will not be able to proceed with filing a complaint if you do not certify you have read and understand these instructions. If you need language assistance, please contact us via email at labor@nd.gov or by phone at 1-800-582-8032 or 701-328-2660.

In order to file a complaint, you must acknowledge the following:

I understand that the information I submit may be shared with my employer.*

Yes No

STOP: Your complaint will not be processed without your acknowledgement.

I understand that the information I submit must be complete and I must provide sufficient information for the Department to pursue my complaint, and that the failure to provide the requested information may result in the rejection of my complaint.*

Yes No

STOP: Your complaint will not be processed without your acknowledgement.

I understand that anything I submit in a paper form will be scanned to an electronic version and the original destroyed.*

Yes No

STOP: Your complaint will not be processed without your acknowledgement.

I agree to provide the Department with contact information where I can be reached and to promptly respond to Department inquiries and requests.*

Yes No

STOP: Your complaint will not be processed without your acknowledgement.

Complaint Information

Your Name*

First Name

Last Name

Your Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Do you have an email address?*

Yes No

Your Email*

Do you consent to receiving correspondence exclusively at this email address?*

Yes No

Your Phone Number

Phone Number Type

Home Cell Work

Other:

Name of Business* (Search the ND Secretary of State website here for the proper name and mailing address.)

Business Mailing Address on record with ND Secretary of State*

Address Line 1

Address Line 2

City

State

ZIP Code

Business Phone Number

Business contact name

First Name

Last Name

Describe the Situation. Be as specific as possible - include names, dates, places, etc. (For final paycheck, please include: hourly rate, hours worked, and dates worked.)*

Signature

By typing my name here and checking this box, I certify that the information I have provided is true and correct, and I adopt this as my online signature.

Signed by*

Declaration of online signature*

Yes No

STOP: Your complaint will not be processed without your acknowledgement.