Former Employees of HMP Industries Group in Ansonia Eligible to Apply for Trade Act Benefits
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STATEMENT OF COMPLAINT Employer Not Reporting Employees For Connecticut Unemployment Compensation Purposes
Business (Employer Information): Date
Name Owner/Officer Address
Telephone Number
Connecticut Department of Labor ● www.ct.gov/dol An Equal Opportunity/Affirmative Action Employer -2-
Type of Business Hours of Operation (if known)
Work location(s) and time of day when the work is being performed:
Name and Title of person in charge at each location: (Owner, Manager, Forman, etc.)
Connecticut Department of Labor ● www.ct.gov/dol An Equal Opportunity/Affirmative Action Employer -3-
Nature of Complaint: (Include names of unreported employees)
Approximate number of employees not reported: Dates Occurring: From: To:
Connecticut Department of Labor ● www.ct.gov/dol An Equal Opportunity/Affirmative Action Employer -4-
Your Information (Optional): Name Address Tel. Number Signed
Instructions: 1. Please print or type, or complete on-line, print, and send or fax to the address below. 2. Include any information that may be helpful in investigating your complaint, including relevant supporting documentation.
Return To: Connecticut Department of Labor – Field Audit Unit 200 Folly Brook Blvd. Wethersfield, CT 06109 Fax (860) 263-6379
Connecticut Department of Labor ● www.ct.gov/dol An Equal Opportunity/Affirmative Action Employer -5-
Connecticut Department of Labor ● www.ct.gov/dol An Equal Opportunity/Affirmative Action Employer