New York State Department of Labor (NYSDOL) Division of Labor Standards Complaint Form (LS 223) Instructions

Enter the business's regular hours of operation including days and times (for example, “Mon–Fri 9:00 AM–5:00 PM”, “Weekends 10 AM–4 PM”, or “24 hours”).

Enter the total number of employees currently employed by the company, including full‑time and part‑time staff (provide a numeric count).

Check this box if the business is primarily a restaurant or food service establishment.

Check this box if the business is primarily a retail store selling goods to customers.

Check this box if the business is primarily engaged in domestic help or household/personal care services.

Check this box if the business is primarily engaged in construction, contracting, or related trades.

Check this box if the business is primarily an office-based operation (administrative, professional, or clerical work).

Check this box if the business type is not listed above and write a brief description on the 'Other' line.

Enter the business type description when the listed categories do not apply; provide the specific nature of the business (e.g., "landscaping service," "consulting firm"). Fill only if 'Other' is 'Yes'.

Enter the full name of the business or employer the claim is being filed against as shown on bills, signs, or official records.

If the company operates under a different trade name, enter the business's official legal name (for example, the name registered with the state); leave blank if the legal name is the same as above. Fill only if 'Business name (8a)' is different.

Enter the 3-digit area code for the business phone number of the party the claim is filed against.

Enter the next three digits (prefix/exchange) of the business phone number for the party the claim is filed against.

Enter the final four digits of the business phone number for the party the claim is filed against.

Enter the email address for the business or business owner that the claim is filed against.

Check this box if the claim is filed against an individual person (a natural person or sole proprietor).

Check this box if the claim is filed against a limited liability company (LLC).

Check this box if the claim is filed against a business organized as a partnership.

Check this box if the claim is filed against a corporation (an incorporated business entity).

Check this box if the claim is filed against a legal entity type not listed above and write the entity type on the provided line.

If the business’s legal entity does not match the listed options (Individual, LLC, Partnership, Corporation), enter the specific entity type or description here. Fill only if 'Other (specify)' is 'Yes'.

Enter the business's street mailing address (street number and name) for the entity the claim is filed against.

Enter the floor, room, or suite number associated with the mailing address, if applicable.

Enter the city or town of the business's mailing address.

Enter the county in which the business's mailing address is located.

Enter the state for the business's mailing address (abbreviation or full name).

Enter the ZIP code for the business's mailing address.

Check this box if the company is still operating/in business at the time of completing this form.

Check this box if the company is no longer operating/in business at the time of completing this form.

Enter the date the company ceased operations (the business closing date). Fill only if '13a. Is the company still in business? No' is 'Yes'.

Enter the month you were hired.

Enter the day of the month you were hired.

Enter the year you were hired.

Enter the full name and job title of the person who hired you.

Enter the employer’s bank name and the bank branch location (for example branch address, city and state) where the employer’s account is held; attach a copy of a check or check stub if available.

Check this box if you know the employer has filed for bankruptcy.

Check this box if you know the employer has not filed for bankruptcy.

Check this box if you do not know or cannot determine whether the employer has filed for bankruptcy.

Check this box if you were paid every day (your pay frequency was daily).

Check this box if you were paid once every week (your pay frequency was weekly).

Check this box if you were paid every two weeks (biweekly pay).

Check this box if your pay frequency is not listed and write the specific frequency on the provided line.

Enter the pay frequency if it is not one of the listed options (for example, “Biweekly,” “Semi‑monthly,” “Monthly,” or any other schedule). Fill only if 'Other' is 'Yes'.

Enter the month of your last day worked (numeric month, e.g., 01 for January).

Enter the day of the month of your last day worked (numeric day, e.g., 15).

Enter the year of your last day worked.

Provide a brief explanation for why you left this job (for example: quit, discharged, laid off, employer closed, or resigned for personal reasons).

Enter the street address for the mailing address, including house number, street name, and any directional information.

Enter the apartment, unit, or suite number for the mailing address, or leave blank if none.

Enter the city or town for the mailing address.

Enter the county in which the mailing address is located.

Enter the state or province for the mailing address (postal abbreviation or full name).

Enter the ZIP or postal code for the mailing address.

Enter the full name(s) of the manager(s), supervisor(s), or foreman who directly oversaw your work at this job.

Enter the full name of the individual who issued or authorized your pay (for example a payroll clerk, manager, or employer representative).

Enter the Labor Standards identification number or code assigned to this complaint for office tracking.

Enter the office LCM reference code used to categorize or route this complaint.

Enter the PV reference code or value used internally for this complaint.

Enter the priority level or priority code assigned to this complaint.

Enter the name or initials of the staff member who took this complaint.

Enter the month of the date the complaint was taken (e.g., 01–12).

Enter the day of the date the complaint was taken (e.g., 01–31).

Enter the year of the date the complaint was taken (preferably four digits, e.g., 2026).

Enter the employee's overtime pay rate — the hourly rate paid for overtime work.

Enter the 3-digit area code for the owner’s phone number (digits only).

Enter the next 3 digits (central office/prefix) of the owner’s phone number (digits only).

Enter the final 4 digits of the owner’s phone number (digits only).

Enter the owner’s email address (for example: [email protected]).

Enter the full name or names of the owner(s) and each owner’s title (for example: President, CEO, Partner) as it should appear on the form.

Enter the pay period this wage payment covered — provide the range of days or specific start and end dates or a short phrase (for example, “Sat through Fri” or “01/01/2026 - 01/14/2026”).

Check this box if your payday fell on Monday.

Check this box if your payday fell on Tuesday.

Check this box if your payday fell on Wednesday.

Check this box if your payday fell on Thursday.

Check this box if your payday fell on Friday.

Check this box if your payday fell on Saturday.

Check this box if your payday fell on Sunday.

Enter the email address where the person filing the claim can be contacted.

Enter the filer’s primary or preferred language for correspondence and communications.

Enter your street mailing address including house number and street name.

Enter your apartment, unit, or suite number if applicable, or leave blank if none.

Enter the city or town for your mailing address.

Enter the county where your mailing address is located.

Enter the state for your mailing address (e.g., full name or standard two-letter abbreviation).

Enter the ZIP code for your mailing address.

Enter the claimant's first (given) name as it should appear on the complaint form.

Enter the claimant's middle name or initial, if any; leave blank if none.

Enter the claimant's last (family/surname) name as it should appear on the complaint form.

Enter any other name you are/ were known by at your workplace (for example a nickname, maiden name, alias, or previous legal name) as a single-line text entry.

Enter the three-digit area code for your primary phone number (numbers only).

Enter the three-digit prefix (the first three digits after the area code) of your primary phone number.

Enter the four-digit line number (the last four digits) of your primary phone number.

Enter the three-digit area code for your alternate/other phone number (numbers only).

Enter the three-digit prefix (the first three digits after the area code) of your alternate/other phone number.

Enter the four-digit line number (the last four digits) of your alternate/other phone number.

Enter the regular amount you were paid (dollar amount) corresponding to the pay period indicated on the form.

Check this box when your rate of pay is a daily (per day) amount.

Check this box when your rate of pay is a weekly (per week) amount.

Check this box when your rate of pay is an hourly (per hour) amount.

Check this box when your pay is based on a different period or basis (e.g., per month, per piece) and specify that period in the adjacent 'Other' field.

If the pay period is not Day, Week, or Hour, type the custom pay period (for example, 'Bi-weekly', 'Monthly', 'Per job', etc.). Fill only if 'Per Other (specify)' is 'Yes'.

Check this box if, during the period of employment covered by this claim, you regularly traveled outside New York State for work.

Check this box if, during the period of employment covered by this claim, you did not regularly travel outside New York State for work.

Check this box if you are still employed by the business at the time you are filing this form.

Check this box if you were discharged (fired, terminated, or laid off permanently) from your employment with the business.

Check this box if you voluntarily quit or resigned from your job with the business.

Check this box if you were temporarily laid off or furloughed from the business with an expectation of possible return.

Check this box if you regularly earned tips as part of your compensation.

Check this box if you did not regularly earn tips as part of your compensation.

Enter the average amount of tips you earned per hour during the period in question. Fill only if 'Earned tips on a regular basis — Yes' is 'Yes'.

Check this box if your employer did not keep any of your tips or other employees' tips.

Check this box if your employer kept your tips (but not other employees' tips).

Check this box if your employer kept tips that belonged to other employees.

If your employer kept any of your tips, enter how much was kept and provide a short explanation of the circumstances (who kept them, when, and why). Fill only if 'Employer kept tips — Yes (yours)', 'Employer kept tips — Yes (others')' is 'Yes' (any).

Enter a clear, concise description of the work you performed (job duties, tasks, and/or job title) at this employer.

Check this box if you were a member of a labor union for the job described.

Check this box if you were not a member of a labor union for the job described.

Enter the union local number associated with your membership (the numeric/alpha identifier for your local union). Fill only if '26a. Union member — Yes' is 'Yes'.

Enter the street address of the worksite, including building number and street name (e.g., 123 Main St).

Enter the floor, room, apartment or suite number for the worksite location, or leave blank if not applicable.

Enter the city or town where the worksite is located.

Enter the county in which the worksite is located.

Enter the state where the worksite is located (use the state name or standard postal abbreviation).

Enter the postal ZIP code for the worksite.

Enter the job title or position you held at the employer (the official or commonly used title you performed) at the time relevant to this claim.