Labor-complaint.docx

Republic of the Philippines Department of Labor and Employment Region 7 Cebu City _____________________ and/or _____________________, Complainant/s

Date: _________________

-versus – NLRC-Region 7 CASE NO. _______________________ _____________________ and/or _____________________ Respondent/s x-----------------------------------------------x COMPLAINT Complaint/s, by counsel, respectfully state/s, that: 1. Name of complainant: _____________________________ Sex: ____ Age: ____ Status: ___ 2. Dependent of Complainant/s: (M) _______ (F) _______ 3. Address:___________________________________________________________________ _____________________________________________________Zip Code: ____________ 4. Name of Respondent Company: ________________________________________________ 5. Address:___________________________________________________________________ _____________________________________________________ Zip Code: ____________ 6. Represented by: Owner ( ) Manager ( ) President ( ):___________________________ 7. Nature of Business: ______________________ Number of workers: ___________________ Date Employed: ____________________ Date Dismissed: __________________________ 8. Nature of work/position: _____________________ Work Schedule: ___________________ Place of Work: ______________________________________________________________ 9. Salary Rate: _____________________ Frequency of Payment: _______________________ 10. Are you a union member? ( ) Yes ( ) No Name of Union: _____________________________________________________________ 11. Is there an existing CBA? ( ) Yes ( ) No 12. Have you filed any similar case elsewhere? ( ) Yes ( ) No If Yes, Where? ____________________________________________________________ ………………………………………………………………………………………….. This portion is to be filled up by the Complaint Officer, unless complainant/s is with legal counsel

CAUSE OF ACTION A. Illegal Dismissal ACTUAL ( ) CONSTRUCTIVE ( ) B. Illegal Suspension ( ) C. Illegal lay-off ( ) D. Regularization ( ) E. Underpayment ( ) Non-payment ( ) 1. Salaries/Wages ( ) 2. Overtime Pay ( ) 3. Holiday Pay ( ) 4. Premium for Holiday Pay ( ) Rest Day ( ) 5. Service Incentive Leave ( ) 6. 13th month pay ( ) 7. Separation Pay ( ) 8. Retirement Benefits ( ) (See back page)

F. Illegal Deduction ( ) Specify: __________________________ _________________________________ _________________________________ G. Unfair Labor Practice ( ) Specify: ___________________________ __________________________________ __________________________________ H. Damages Moral and Exemplary ( ) Actual ( ) I. Attorney’s Fees ( ) J. Others: Specify: ____________________ __________________________________ __________________________________ __________________________________ __________________________________

R E L I E F Complainant/s pray for the following: A. Reinstatement ---------------------------- ( ) and B. Payment of (specify) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Other relief a just and equitable under the premises are likewise prayed for. Done in Quezon City this __________ day of ____________________. 20 __. ____________________________________ Complainant (2)

_____________________________________ Complainant (1)

Address:_____________________________ ____________________________________ ____________________________________ _______________ Zip code: ____________ Date Employed: ______________________ Date Dismissed: ______________________ Position: ____________________________ Salary Rate: _________________________

_____________________________________ Counsel for complainant/s Address: _____________________________ _____________________________________ ___________________ Zip Code: _________ PTR No.: _____________________________ IBP No.: _____________________________

VERIFICATION I / We __________________________________, having been duly sworn to, (jointly and severally, shall subscribe and be sworn to) in accordance with law, hereby depose ad state that: I / We am/are the complainant/s in the above-entitled case; I / We have read the contents hereof and declare the same to be true to the best of my/own knowledge and belief. CERTIFICATION OF NON-FORUM SHOPPING This is to certify that I / We have not filed any similar case with any other Court, QuasiJudicial Court or government agency. ____________________________________ Complainant (2)

_____________________________________ Complainant (1)

SUBSCRIBED AND SWORN to before me this _____ day of ____________________, Quezon City, affiant/s exhibiting to me his/her/their Community Tax Certificate No./s _________________ Issued on ____________________ at ________________________.

Prepared by: ________________ Complaint Officer Date:____________________

_______________________ Administering Officer