FLWPA Complaint Form

Panel for FLW
Panel for Hiring Entity
Panel Work Details
Panel for Complaint
Panel for attachments
Panel for Demographics
Panel for submission

Freelance Worker Protection Act (FLWPA) Complaint Form

FLWPA COMPLAINT:

Please use this form to file a complaint

Email Questions to DOL.FreeLance@illinois.gov.

Freelance Worker (FLW) Information

FLW Name

FLW Address

FLW City

FLW State

FLW Zip Code

FLW Email Address

FLW Phone

I agree to allow the Illinois Department of Labor to email me about my complaint, including sending me documents by email.

Yes

Contracting Entity Information

Contracting Entity Name

Industry

Contracting Entity Address

Contracting Entity City

Contracting Entity State

Contracting Entity Zip Code

Contracting Entity County

Contracting Entity Contact Name

Contracting Entity Contact Phone

Contracting Entity Email Address

Work Details

Please note that this law only applies to contracts that take effect after 7/1/2024.

Contract Start Date

Contract End Date

I had multiple contracts with this contracting entity.

Yes

Rate and Method of Compensation

Total Contract Value ($)

Short Description of Services/Scope of Work

Complaint Reason Details

Check the box(es) to indicate reason(s) for filing this Complaint.

I was denied a written contract from the contracting entity, or the contract did not include all of the required information.

I did not receive full payment for the services by the due date in the contract, or if the due date is not specified, within 30 days of completing the services outlined in the contract.

A negative action was taken against me for requesting a contract or requesting timely payment under the Act.

If you are seeking payment for unpaid amounts due under the contract, please confirm the following information:

Date work was completed

Due date for payment

Total amount you claim you are owed

Total amount you were actually paid (i.e. amount of money you actually received)

Explain why you believe there was a violation of the Freelance Worker Protection Act. List dates, hours, whether the work was fully or partially performed, and other specific details that support your complaint.

If offered by the Illinois Department of Labor, I would like to participate in a mediation of this claim.

Yes

Attachment(s)

Please attach any of the following documents if you have them:

A copy of the contract(s) or agreement(s) between the freelance worker and the contracting entity.
Any relevant communications between the freelance worker and the contracting entity.
Proof of any payment that you have received.

Attachment(s)

Demographic information

IDOL asks for this voluntary information in order to learn more about the people who file complaints with us. Any information you provide will not be shared or used in relation to your complaint.

What is your race?

What is your ethnicity?

What is your gender identity?

What is your sexual orientation?

Do you have a disability?

What is your primary language?

I understand that in general the public has the right, under FOIA, to request most information kept as part of any public record, however, the IDOL, will endeavor to keep the confidentiality of a complainant or witness to the maximum extent allowable by law.

I hereby certify that the application, including attachments, is true and accurate to the best of my knowledge.

Name

Date

FLWPA Complaint Form

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