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Vermont Department of Labor
Wage Complaint Form

WAGE and HOUR PROGRAM
63 Pearl Street
Burlington, VT 05401-4331
Telephone: 802-828-0267 FAX: 802-863-7655
Email: Labor.WageHour@vermont.gov

Wage Complaint Form

  • Your Information


  • Business Information


  • Section 1 - Complaint Basis

  • * If this is NOT a claim for wages you may STOP here. Please sign and date below. Otherwise continue to the next page and complete Sections 2 and 3.

    I hereby certify that, to the best of my knowledge, this statement is true. I understand a copy of this claim, and any materials that I submit to the Wage & Hour Program relative to this will be forwarded to my employer and/or my employer's representative.

  • Section 2 - Wage Claim Information

    Week 1
  • Week 2
  • Week 3
  • Week 4

  • Reimbursement Claim Information

    Week 1
  • Week 2
  • Week 3
  • Week 4

  • Improper Deductions Information

    Week 1
  • Week 2
  • Week 3
  • Week 4

  • Unpaid Leave Claim Information

    Week 1
  • Week 2
  • Week 3
  • Week 4
  • * You cannot file a claim for wages more than two years after the date they are due.

    Section 3 - Employment Agreement Information

  • I hereby certify that, to the best of my knowledge, this statement is true. I understand that a copy of this claim, and any materials that I submit to the Wage and Hour Program relative to this claim, will be forwarded to my employer and/or employer's representative.
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