Form WH-4 Nonimmigrant Worker Information Form

U.S. Department of Labor

Nonimmigrant Worker
Information Form

Wage and Hour Division

OMB NO: 1205-0310
Expires: xx/xx/20xx
This report is authorized by certain Immigration and Nationality Act provisions. 8 U.S.C. §§ 1182(n)(2)(A), 1182(n)(2)(G), and 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.
Instructions: Please provide as much of the requested information as possible. Your identity will be kept confidential to the extent provided by the law. 5 U.S.C. § 552(b)(7)
(D). If necessary, attach additional sheets to this form if you need more space to answer. If you do not understand a term, or need assistance in the completion of this
form, please contact the U.S. Department of Labor Wage and Hour Division (WHD) at 1-866-4USWAGE (1-866-487-9243). Once you complete this form, please mail or
otherwise deliver it to the WHD office that has jurisdiction over the physical location of the employer. For WHD office locations visit http://www.dol.gov/contacts/whd/
america2.htm. After you submit this form, a representative from the Wage and Hour Division may contact you if further information is necessary to initiate an investigation.
The Immigrant and Employee Rights Section of the U.S. Department of Justice, Civil Rights Division, handles complaints alleging failure to offer employment to an equally or
better qualified U.S. worker or a misrepresentation regarding such offer(s) of employment. If your allegations concern such matters, please file your complaint with the
Immigrant and Employee Rights Section at https://www.justice.gov/crt/filing-charge. You may also call the toll-free Worker Hotline at 1-800-255-7688 or 1-800-237-2515
(TTY).

1. Person Submitting Information (please print)

First Name

Middle Initial

Last Name

Mailing Address:
Number, Street, Apt., or P.O. Box No.

City

State

ZIP Code

Telephone Number (including area code)
Email Address:
Best means to contact you:

2. Status. Please identify the status under which you are filing this complaint.
Nonimmigrant Worker (please choose visa classification below)
H-1B

H-1B1

E-3

U.S. Worker
Job Applicant
Date of Application:
Competitor Business (please specify business name)

Federal Government Agency (please specify agency)

State or Local Government Agency (please specify agency)

Community or Service Organization (please specify organization)

Other (please specify)

Page 1

- Continued on next page -

Form WH-4
REV xx/20xx

3. Information on Company or Entity Committing Alleged Violation(s). Please provide the information below on the company or entity that
committed the alleged nonimmigrant program violation(s).
Name of Company/Entity:

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

City

State

ZIP Code

Representative to be Contacted:
Telephone Number (including area code):

If the company or entity named above employed you, please identify the dates of employment and your job title/occupation.
Dates of Employment:

to

Job Title/Occupation:

Did the company or entity identified above place nonimmigrant workers with another company or entity?

Yes
No
I don't know
If yes, please identify the name of the company or entity where nonimmigrant workers were placed.

Page 2

- Continued on next page -

Form WH-4
REV xx/20xx

4. Description of Alleged Violation(s)
Please check the appropriate box(es) that best describe the alleged violation(s) of the applicable nonimmigrant worker provisions of the Immigration and Nationality
Act which you believe have occurred.

Employer supplied incorrect or false information on the Labor Condition Application (LCA).
Employer failed to pay nonimmigrant worker(s) the higher of the prevailing or actual wage.
Employer 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.
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.
Employer 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).
Employer does not afford nonimmigrant worker(s) working conditions (hours, 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).
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.
Employer 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.
Employer required nonimmigrant worker(s) to pay all or any part of the scholarship and training fee (ACWIA fee).
Employer 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.
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).
Employer failed to maintain and make available for public examination the LCA and necessary documents at the employer's principal place of
business or worksite.
Note: The following items do not apply to H-1B1 or E-3 workers. An H-1B dependent employer is one who employs 25 or fewer full-time equivalent employees
employed in the U.S. and at least eight H-1B nonimmigrant workers; or 26-50 full-time equivalent employees employed in the U.S. and at least 13 H-1B nonimmigrant
workers; or 51 or more full-time equivalent employees employed in the U.S. and 15% or more are H-1B nonimmigrant workers. INA 212(n)(3)(A), 20 CFR 655.736(a). An
H-1B willful violator is an employer found to have committed either a willful failure or a misrepresentation of material fact by either DOL (INA 212(n)(2)) or the
Department of Homeland Security (INA 212(n)(5)) during the five-year period preceding the labor condition application filing.

H-1B dependent/willful violator employer displaced U.S. worker(s) in its own workforce within 90 days before or after filing H-1B visa
petitions.
H-1B dependent/willful violator employer placed H-1B workers(s) at another employer's worksite where U.S. workers have been displaced
within 90 days before or after placement of the H-1B worker(s), and/or has failed to inquire of the second employer whether it has or intends to
displace U.S. worker(s) within 90 days before or after placement of the H-1B worker(s).
H-1B dependent/willful violator employer failed to recruit U.S. worker(s) for jobs for which H-1B worker(s) are sought.

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. Allegations of 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 Immigrant and Employee Rights Section of the
U.S. Department of Justice, Civil Rights Division at https://www.justice.gov/crt/filing-charge. You may also call the toll-free
Worker Hotline at 1-800-255-7688 or 1-800-237-2515 (TTY).
Other:

Page 3

Form WH-4
REV xx/20xx

5. Dates of Alleged Violation(s)
6. LCA number(s) under which the Alleged Violation(s) Were Committed (if known):
7. Location of Worksite(s) Where Alleged Violation(s) Occurred (Use additional sheets of paper, if necessary):

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

City

State

ZIP Code

8. Basis of Knowledge of Alleged Violation(s). Please describe how you know of the alleged violations, and for each item checked in section 4,
please describe, in as much detail as possible, the facts and circumstances which cause you to believe that violations have occurred.

To the best of your knowledge, do these alleged violations affect other H-1B workers employed by the employer?

Yes

No

If yes, please explain how you know that other H-1B workers are affected.

9. Description of facts and circumstances which support allegations in Section 4. Use additional sheets of paper, if necessary.

FOR DOL USE ONLY
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. While you are not required to respond, your cooperation is needed for the Wage and Hour Division to process your
complaint. Immigration and Nationality Act, § 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.
In accordance with the Privacy Act, 5 U.S.C. § 552a; and its respective regulations, the authority for this collection of information is derived from 8 U.S.C. § 1182.
Routine Uses: The information will be used by and disclosed to DOL personnel and contractors or other agents who need the information to assist in activities related to
employer compliance with the Labor Condition Application and law enforcement. Additionally, DOL may share the information pursuant to its published Privacy Act
system of records notice.
Date:

Complaint Received/Taken By:
Source of Complaint is:
Page 4

Aggrieved party

Credible source
Form WH-4
REV xx/20xx