Form WH-4 Nonimmigrant Worker Information Form

Nonimmigrant Worker U.S. Department Of Labor

Information Form Wage and Hour Division

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OMB Control No.: 1205-0310 Expiration Date: 03/31/2015

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This report is authorized by the American Competitiveness and Workforce Improvement Act (ACWIA) of 1998. 8 U.S.C.

§§ 1182(n)(2)(G), 1182(t)(3)(A). The information provided on this form will assist the U.S. Department of Labor (DOL) in determining whether the named employer of H-1B, H-1B1 or E-3 nonimmigrant(s) has committed a violation of provisions of the applicable nonimmigrant program. Your identity will be kept confidential to the fullest extent provided by law. 5 U.S.C. § 552(b)(7)(D). Please provide as much of the requested information as possible. Attach additional sheets if you need additional space to respond to a question. If you do not understand a term, or need assistance in the completion of this form, please contact the Wage and Hour Division of the U.S. Department of Labor: 1-866-4USWAGE (1-866-487-9243). After you submit the form, a representative from the DOL may contact you if further information is necessary to initiate an investigation.

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1. Person Submitting Information (please print)

Mr., Miss, Mrs., Ms.: ______________________________________________________________________________________________

First Name Middle Name Last Name

Current Address: ______________________________________________________________________________________________

Number, Street, Apt., or P.O. Box No.

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City, State, ZIP Code

Telephone Number (including area code): _____________________________________________________________________________

Days/Times When You Can Be Reached at that Number: _________________________________________________________________

E-Mail Address (optional): _________________________________________________________________________________________

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2. Nature of Source’s Relationship to Employer (Please check all that apply)

1. Nonimmigrant Worker H-1B H-1B1 E-3

Former or Current Employee (dates of employment): __________________________________

(b) U.S. Worker

Former Current Employee (dates of employment): __________________________________

(c) Job Applicant (date of application): ___________________________________________________________________

(d) Competitor Business (please specify): ___________________________________________________________________

(e) Federal Government Agency (please specify): ____________________________________________________________

6. State or Local Government Agency (please specify): _______________________________________________________

( g) Community or Service Organization (please specify): _______________________________________________________

(h) Other (please specify): _______________________________________________________________________________

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3. Information on Employer Committing Alleged Violation(s)

Name of Employer/Company:

Address: ________________________________________________________________________________________________________

Number, Street City, State ZIP Code

Employer Representative to Be Contacted: _____________________________________________________________________________

Telephone Number (including area code): ________________________________________________________________________

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4. Description of Alleged Violation(s)

Please check the appropriate box(es), (a) through (q), which best describe the violation of the applicable nonimmigrant worker

provisions of the Immigration and Nationally Act which you believe have occurred. In Section 8, identify each item checked and describe, in as much detail as possible, the facts and circumstances which cause you to believe that violations have occurred. (Note. Items m, n, o, and p do not apply to H-1B1 or E-3 workers).

1. E mployer supplied incorrect or false information on the Labor Condition Application (LCA).

2. E mployer failed to pay nonimmigrant worker(s) the higher of the prevailing or actual wage.

2. E mployer failed to pay nonimmigrant worker(s) for time off due to a decision by the employer (e.g., for lack of work) or for time needed by the nonimmigrant worker(s) to acquire a license or permit.

2. Employer made deductions from nonimmigrant worker’s wage (e.g., for nonimmigrant petition processing; for food and housing expenses when the nonimmigrant worker is traveling on the employer’s business; for tools and equipment necessary to perform employer’s work) that caused the wages paid to fall below the nonimmigrant worker’s required wage.

2. E mployer failed to provide fringe benefits to nonimmigrant worker(s) equivalent to those provided to U.S. worker(s) (e.g., cash bonuses, stock options, paid vacations and holidays, health benefits, insurance, retirement and saving plans.

2. E mployer does not afford nonimmigrant worker(s) working conditions (hour, shifts, and vacation periods) on the same basis as it does U.S. worker(s), or the employment of nonimmigrant worker(s) adversely affects the working conditions of U.S. worker(s).

2. Employer failed to comply with “no strike/lockout” requirement by: 1) placing or contracting out nonimmigrant worker(s) during the validity period of the LCA to any place of employment where there is a labor dispute; 2) failing to notify the DOL, within 3 working days of the occurrence, of such a labor dispute; or 3) using an LCA for nonimmigrant worker(s) to work at a site before the DOL has determined that a labor dispute has ended.

2. E mployer failed to provide employees or their collective bargaining representative, either by hard copy posting or electronically, notice of its intentions to hire nonimmigrant worker(s), or has failed to provide nonimmigrant worker(s) with a copy of the LCA.

2. E mployer required nonimmigrant worker(s) to pay all or any part of the scholarship and training fee (ACWIA fee).

2. E mployer imposed an illegal penalty (as opposed to liquidated damages permissible under state law) on nonimmigrant worker(s) for ceasing employment with the employer prior to a date agreed upon by the nonimmigrant worker and the employer.

2. Employer retaliated or discriminated against an employee, former employee, or job applicant for disclosing information, filing a complaint, or cooperating in an investigation or proceeding about a violation of the applicable nonimmigrant program laws and regulations (i.e., whistleblower).

2. E mployer failed to maintain and make available for public examination the LCA and necessary documents at the employer’s principal place of business or worksite.

2. H-1B dependent/willful violator employer laid off U.S. worker(s) and has replaced or seeks to replace U.S. worker(s) with H-1B worker(s) within 90 days before or after filing H-1B visa petitions.

2. H -1B dependent/willful violator employer placed H-1B workers(s) at another employer’s worksite where U.S. workers have been laid off, and /or has failed to inquire of the second employer whether it has or intends to lay-off U.S. worker(s) and replace them with H-1B worker(s).

2. H-1B dependent/willful violator employer failed to recruit U.S. worker(s) for jobs for which H-1B worker(s) are sought.

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2. H-1B dependent/willful violator employer failed to hire a U.S. worker who applied and was equally or better qualified for the job for which the H-1B worker was sought. Complaints alleging failure to offer employment to an equally or better qualified U.S. worker, or a misrepresentation regarding such offer(s) of employment, may be filed with the U.S. Department of Justice, Office of Special Counsel for Immigration-Related Unfair Employment Practices, 950 Pennsylvania Avenue, NW., Washington, DC 20530.

2. Other: ____________________________________________________________________________________________

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5. Date(s) of Alleged Violation(s): _____________________________________________________________________________________

6. Location of Worksite(s) where Alleged Violation(s) occurred: ___________________________________________________________

7. Basis of Knowledge of Alleged Violation(s): __________________________________________________________________________

8. Description of facts and circumstances which support allegations in Section 4, items (a) through (q). Use additional sheets of paper, if necessary.

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Notice. Persons are not required to respond to an information collection unless it displays a currently valid OMB control number. These reporting instructions have been approved under the Paperwork Reduction Act. Obligations to reply are voluntary. Immigration and Nationality Act, section 212(n)(G)(ii). Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time to review instructions, search existing data sources, gather and maintain the data needed, and complete and review the collection of information. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Room S-3502, 200 Constitution Ave., NW, Washington, DC 20210.

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FOR DOL USE ONLY

C omplaint Received/Taken By: Date:

S ource of Complaint is: Aggrieved party Credible source

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Form WH-4

Rev. XXXX