16
State of Rhode Island and Providence Plantations
Rhode Island Department of Labor and Training
LABOR STANDARDS UNIT – BLDG. 70/2
1511 Pontiac Avenue. P.O. Box 20390
Cranston, RI 02920-0944
NON—PAYMENT OF WAGES COMPLAINT FORM
Complete both sides of this form, sign and return to the address above; do not fax or email. Type or print clearly.
Incomplete forms will be returned. Complete ALL items to the best of your knowledge. Enclose any copies of
documentation that may be relevant to your claim. Please notify this oce immediately by mail if you have a change
of address, phone number or have been paid.
EMPLOYEE INFORMATION:
1. First and Last Name: ______________________________________________________________________________
2. Last 4 Digits of your Social Security #: ________
3. Address (Number & Street): _________________________________________________________________________
City/Town: _______________________________________________ State: _______________ Zip Code: ___________
4. Home phone: _________________ 5. Cell phone: ________________ 6. Email: _______________________________
7. Title/Occupation or Type of Work Done: _______________________________________________________________
EMPLOYMENT INFORMATION: (complaint will not be accepted unless this section is completed.)
8. Business Name: _________________________________________________ 9. Business Phone: _________________
10. Business Address (Number & Street, NOT P O Box): _____________________________________________________
Business City/Town: __________________________________________ State: __________ Zip Code: ____________
11. Other Business Name (s) that might be used by employer: ______________________________________________
12. Name of Person In Charge: __________________________________13. Title: _______________________________
14. Did you work at business address listed above?
Yes No
If no, please provide the location where you did work: _________________________________________________
15. Hours per week: ____________ 16. Wage Rate: ____________
17. Type of Wage:
Hourly Salary Commission Other, please explain: _____________________
18. Date hired: _________________________ 19. Date of separation: _________________________
20. Reason for separation (layo, quit, etc): _____________________________________________________________
21. Are you represented by an attorney?
Yes No
If yes, please provide the attorney’s name: ___________________________________________________________
22. Please check all the reason(s) why you are ling this claim:
Final paycheck not received Commission not received/incorrect
Vacation pay upon termination* Minimum wage
No paystub Sunday or holiday premium pay
Improperly classied as an Bounced paycheck
Paid Sick/Safe Leave
Overtime wages
Minimum shift
Illegal deductions
Independent Contractor
* If checked, please provide a written copy of the vacation policy
OFFICIAL USE ONLY:
Case Number: _______________________
Date Received: _______________________
Dated Closed: ________________________
Examiner: ___________________________
Page 1 of 2
Form: Nonpayment of Wages Complaint Form
Audience: Employees
Purpose: Report nonpayment of wages
Form: Mandatory Overtime Complaint Form
Audience: Nurses and Certied Nurse Assistants
Purpose: Report forced overtime
Rhode Island Department of Labor and Training
INTENTION TO EMPLOY MINOR
Print in Ink, or Type, or on-line (except signature) (Adobe Reader 5.0 and above)
Employer’s Affidavit
THIS ESTABLISHMENT WILL EMPLOY THE MINOR
NAMED HEREIN, SUBJECT TO ALL PERTINENT LAWS
& REGULATIONS. EMPLOYER ASSUMES
RESPONSIBILITY TO ASCERTAIN THAT THE MINOR IS
OF LEGAL AGE FOR ANY OCCUPATION ASSIGNED
.
8. Signature of Employer Date
9. Print Signer’s Name and Title
PARENT’S APPROVAL
I HEREBY GIVE PERMISSIONS FOR THE MINOR NAMED
AT LEFT TO ENTER EMPLOYMENT AS HEREIN DESCRIBED
10. Signature of Parent or Guardian (in ink)
11. Address of Parent or Guardian
Check
one:
14-15 Years of Age
SPECIAL LIMITED PERMIT
TO WORK
(Mandatory under law)
16-17 Years of Age
CERTIFICATE OF AGE
(Advisable for Employer’s
Protection)
1. Full Name of Minor first middle last
2. Address of Minor
3. Business Name of Employer
4. Business Address of Employer
5. Address where minor will perform work (if different from above)
6. Nature of Employer’s Business
7. Minor to be employed as
DLT-L-77 (Rev. 11/2000) CL-1-12/96
RESTRICTIONS -- Hours of Work
MINORS 14-15 years of age:
Maximum hours - RI 8 hours per day, 40 hours per week
Federal - 3 hours per day (school day) - 8 hours non-school day, 18 hours per week (school week - 40 hours, non-school week)
Curfew - RI Employment permitted between the hours of 6 A.M. and 7 P.M. (except 9 P.M. during school vacations)
Federal - Employment between the hours of 7 A.M. and 7 P.M. (except 9 P.M. from June 1st through Labor Day)
THE MORE RESTRICTIVE STANDARD APPLIES WHENEVER THERE IS COVERAGE BY BOTH STATE AND FEDERAL LAW.
Work is prohibited in factories, mechanical, manufacturing, or processing establishments. NO WORK WHEN SCHOOL IS IN SESSION
MINORS 16-17 years of age:
Maximum hours - RI 9 hours per day (9 3/5 per day in a 5 day work week.) 48 hours per week.
Curfew - STUDENTS: Employment permitted between the hours of 6 A.M. and 11:30 P.M. (if no classes are scheduled on the following day,
minor may be employed until 1:30A.M.)
NON-STUDENTS: No Curfew
Certain Occupations have been declared hazardous for 16 and 17 year old workers through the provisions of the Fair Labor Standards Act.
For information regarding Federal Restrictions contact the area office: For information regarding the provisions of Rhode Island laws contact:
Employment Standards Administration Labor Standards Division
United States Dept. of Labor RI Department of Labor and Training
380 Westminister Street, Providence, RI 02903 P.O. Box 20390, Cranston, RI 02920-0944
(401) 528-4431 (401) 462-8550
This application is for employment to take place within the state of Rhode Island. When completed, it is to be presented by MINOR, IN PERSON,
to the issuing officer as designated by the School Committee in the city/town of minor’s residence. A minor who is not a Rhode Island resident must
present this form to the Issuing Officer, so designated, in the city or town where the work is being performed.
All applications must be accompanied by an acceptable proof of age, such as a (1) Birth Certificate, (2) Baptismal Certificate, (3) Bible Records, (4)
Passport, (5) Insurance policy (at least 1 year old), (6) Physician’s Certificate ofAge accompanied by school records of age and parents affidavit, (7)
Rhode Island Motor Vehicle Operator ’s license with photograph.
Minors 14-15 may not start work until employer has been issued the necessary permit;
Minors 16-17 may not be employed beyond the curfew until the employer has been issued a certificate of age verifying the non-student status.
Number
Date
1. Employer
2. Labor Dept.
3. Issuer
Check Orig Reissue
Rhode Island Department of Labor and Training
SPECIAL LIMITED PERMIT TO WORK
for a Minor 14-15 Years of Age
Print in Ink, or Type on-line, (except signatures) CL-2-6/80
1. Full Name of Minor first middle last 15. Name of Parent or Guardian
2. Address of Minor 16. Address of Parent or Guardian
3. Age 4. Date of Birth 5. Sex 17. Evidence of Age presented by minor
6. Currently Registered for School? Yes No
7. Last Grade Completed 8. Name of School
18. Signature of Minor
X
9. Business Name of Employer
10. Business Telephone
19.
I hereby certify that I am duly appointed and authorized by the
School Committee for to issue this
special limited permit to the employer named herein for employment of this
minor in the occupation and at the address described. I also certify that I
have reason to believe that the minor named is of the age herein stated.
11. Business Address of Employer 20. Signature of Issuing Officer
12. Address where minor will perform work (if different from above) 21. Telephone Number of Issuing Officer
13. Nature of Employer ’s Business 22. Title of Issuing Officer
14. Nature of work to be performed by minor 23. Date Signed
DLT-L-75 (Rev. 08/2015 mdf) CL-2-6/80
NOTICE TO EMPLOYER
1. This document is valid for employment in Rhode Island only.
2. This document is your property and must be kept with your payroll records. Upon termination of employment, note in your records
for this employee, the certificate number, date of issuance, and city or town from which it was issued, and return this document to the
issuing officer.
3. HOURS OF WORK MINORS 14-15 years of age:
Maximum hours - RI 8 hours per day, 40 hours per week
Federal - 3 hours per day (school day) - 8 hours non-school day, 18 hours per week (school week), 40 hours, non-school week
Curfew - RI Employment permitted between the hours of 6 A.M. and 7 P.M. (except 9 P.M. during school vacation)
Federal - Employment between the hours of 7 A.M. and 7 P.M. (except 9 P.M. from June 1st through Labor Day)
THE MORE RESTRICTIVE STANDARD APPLIES WHENEVER THERE IS COVERAGE BY BOTH STATE AND FEDERAL LAW.
Work is prohibited in factories, mechanical, manufacturing, or processing establishments, docks, warehouses, storage rooms, dispensing gasoline, car washes
and parking lot attendants.
NO WORK WHEN SCHOOL IS IN SESSION. Minors 14-15 may not start work until employer has been issued the necessary permit.
For information regarding Federal Restrictions contact the area office: For information regarding the provisions of Rhode Island laws contact:
Employment Standards Administration Labor Standards Unit
United States Dept. of Labor RI Department of Labor and Training
380 Westminister Street, Providence, RI 02903 P.O. Box 20390, Cranston, RI 02920-0944
(401) 490-2370 (401) 462-8550
DLT is an equal opportunity employer/program - auxiliary aids and services available upon request. TTY via RI Relay: 711
Cert. No.
Date
Make 3 Copies
1. Employer
2. Labor Dept.
3. Issuer
Check(x) Orig. Reissue
Rhode Island Department of Labor and Training
CERTIFICATE OF AGE for Minors 16-17 Years of Age
Print in Ink, or Type or on-line (except Signatures)
1. Full Name of Minor first middle last 15. Name of Parent or Guardian
2. Address of Minor 16. Address of Parent or Guardian
3. Age 4. Date of Birth 5. Sex
17. Evidence of Age presented by minor
(if operator’s license, give #.)
6. Currently Registered for School? Yes No
7. Last Grade Completed 8. Name of School
18. Signature of Minor
X
9. Business Name of Employer
10. Business Telephone
19.
I hereby certify that I am duly appointed and authorized by the
School Committee for to issue this
certificate of age to the employer named herein for the employment of this
minor in the occupation and at the address described. I also certify that I
have reason to believe that the minor named is of the age herein stated.
11. Business Address of Employer 20. Signature of Issuing Officer
12. Address where minor will perform work (if different from above) 21. Issuing Officer Telephone Number
13. Nature of Employer ’s Business 22. Title of Issuing Officer
14. Nature of work to be performed by minor 23. Date Signed
DLT-L-76 (Rev. 08/2015 mdf) CL-3-6/80
NOTICE TO EMPLOYER
1. This document is valid for employment in Rhode Island only.
2. This document is your property and must be kept with your payroll records. Upon termination of employment, note in your records
for this employee, the certificate number, date of issuance, and city or town from which it was issued, then return this document to the
issuing officer. If employee has attained eighteenth birthday at the time of termination, you may give this document to the employee.
3. HOURS OF WORK Minors 16-17 years of age:
Maximum hours - RI 9 hours per day (9 3/5 per day in a 5 day work week.) 48 hours per week.
Curfew - STUDENT: Employment permitted between the hours of 6 A.M. and 11:30 P.M. (if no classes are scheduled on the
following day, minor may be employed until 1:30 A.M.)
NON-STUDENT: No Curfew
Certain Occupations have been declared hazardous for 16 and 17 year old workers through the provisions of the Fair Labor Standards Act.
For information regarding Federal Restrictions contact the area office: For information regarding the provisions of Rhode Island laws contact:
Employment Standards Administration Labor Standards Unit
United States Dept. of Labor RI Department of Labor and Training
380 Westminister Street, Providence, RI 02903 P.O. Box 20390, Cranston, RI 02920-0944
(401) 490-2370 (401) 462-8550
Minors 16-17 may not be employed beyond the curfew until the employer has been issued a certificate of age verifying the non-student
status.
DLT is an equal opportunity employer/program - auxiliary aids and services available upon request. TTY via RI Relay: 711
Intent to Employ a Minor Form
Audience: Employers
Purpose: Required to hire a
minor under 18 years of age
Certication of Age Form for
minors 16-17 years old
Audience: School Departments
Purpose: Required to employ a
minor under 18 years of age
Special Limited Permit to Work for
minors 14-15 years old
Audience: School Departments
Purpose: Required to employ a
minor under 16 years of age
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