Tell Us About Your Employment Matter

Please tell us about your potential employment matter. Everything you tell us on this form is confidential.

Your responses will be sent directly to our Employee Rights Team. We will review and and respond to your questionnaire as soon as possible. We always respond to inquiries within one week, and we usually can respond on the same or the next business day that you finish the questionnaire.

*Please note that we cannot act to preserve or advance your interests or provide advice until and unless we are formally retained in a signed written agreement.

1. Your Contact Information:

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

My age is:

18-39

40 or older (Protected by age discrimination laws)

Younger than 18 (Protected by youth labor laws)

How did you hear about us?

2. Payroll Irregularities -- Check All That Apply. Tell Us About the Past 3 Years.

If you checked any of the boxes above, how often do these issues happen?

What are the name(s) and role(s) of the people who in charge of how you get paid? (In cases about improper pay, these people may be personally liable.)

3. Discrimination & Retaliation -- Check All That Apply. Tell Us About the Past 3 Years.

4. Tell Us About Your Job.

Employer Name:

Your Direct Supervisor's Name:

Employer's Address (Your Location or Managing Office):

Type of Business/Organization (IT, Retail, etc.):

Employer Website:

Number of Employees at Your Location

Number of Employees Overall

Date Hired:

Termination/Quit Date (If Applicable):

Your Job Title:

Your Job Duties:

Approx. Monthly Income:

Benefits (Insurance, etc.)

5. Tell Us About the Problem.

When did the wrongful conduct start?

If applicable, when did it stop?

Please tell us what your employer did that is wrong. It helps us if you include enough names, dates, and details for us to know what happened. However, it is fine to summarize, and we understand it can be difficult to go through it all.

If you were fired or disciplined, what was the formal reason the employer gave?

If applicable, what do you think the real reason was for any termination or discipline, and why was the official reason false?

Please list every witness you believe will voluntarily give us a statement supporting your case if our private investigator calls or visits them. (This is the best kind of witness.)

Please list any other witnesses who may tell the truth if we question them under oath.

Please list every document (including text messages, emails, photos, papers, etc.) you have in your possession that you believe supports your case.

Please tell us about any other helpful witnesses or documents you believe exist, even if we need subpoena them.

6. Tell us about any complaints you have made about these issues.

When did you complain and/or get any Right to Sue letter?

7. Government Fraud. Employees who are the first to report fraud against the government in the millions of dollars may receive a finder's fee. If you know of such fraud, let us know so we can connect you with our firm's government fraud team.

8. Tell us how this has affected you. (E.g. lost income, stress, medical/counseling costs, problems at home.)

9. Check any of the following special circumstances that may apply to your case.

I signed an arbitration agreement with my employer.

I accepted a severance package from my employer.

I am in a union.

I already have a lawyer for this matter, or previously had a lawyer for this matter.

I have a case that is already filed in court or arbitration concerning this matter.

The wrongs I am complaining of occurred more than 10 months ago.

I know other people are being treated in a similar way by my employer.

I think you should know this additional information: I think you should know this additional information:

Please upload up to files you would like us to review. These may include paystubs, text messages, emails, etc. (You do not need to upload files if you do not want to.)

Sometimes we cannot take on a case that we think has merit, but we know another law firm we think may be able and willing to help. If that happens with your case, would you like us to contact the other law firm and ask if they are willing to help? We will let you know if we do that.

Yes. Please speak with other attorneys about my potential case if you know someone who may be able to help.

No. Please do not speak with any other attorneys about my potential case.