Contact Demographics

By providing your contact information you authorize Office of Financial Empowerment and Protection/Consumer Financial Protection Division to contact you.

First Name Your first name, e.g. Jose	Last Name Your last name, e.g. Flores
Date of Birth	What is your address?
What is your city	What is your state
What is your zip code?	What is your phone number?
What is your email address?

What is your gender?

If Other:

How do you identify?

If Other:

What is your preferred language?

If Other:

Reporter Info?

YesNo

Relationship to Complainant

Reporter First Name

Reporter Last Name

Reporter Phone

Reporter Email

Do you feel unsafe or have been threatened with violence? If yes, we encourage you to call the police at their non-emergency police line, 720.913.2000

Please answer the following questions to help Office of Financial Empowerment and Protection/Consumer Financial Protection Division analyze your potential wage theft claims (free). After completing this questionnaire, Office of Financial Empowerment and Protection/Consumer Financial Protection Division will be in touch within two weeks.

Please describe your workplace concern or experience with wage theft.

How much money do you believe your employer owes you? $

enter the Dollar amount without the $ sign, e.g. 1255.50

What is your job title, tasks, duties, or position?

Is it your responsibility to pay workers?

If Other:

Describe your work schedule and estimate the number of hours you work every week.

Are you given 30-minute lunch breaks?

If Other:

Are you given 10-minute breaks every 4 hours?

If Other:

Did you work overtime?

If Other:

Employment Classification

What is your hourly rate?

Between what dates did you work for this employer?

..

Approximately how many workers total work for this employer?

..

Do you have any of the following employment concerns?
To select more than one item, hold down the Ctrl key and click each item you want.

If Other:

Wage theft can cause several short-term problems because you lack the funds to meet expenses. Please tell us whether you would like to be connected with services to help you with any of the following problems:
To select more than one item, hold down the Ctrl key and click each item you want.

If Other:

Has your employer threatened you in any manner, either by making it difficult for you to leave your job or come forward and protect yourself?

Fair Lending

Please provide a detailed description of lending complaint

(If space is insufficient, please upload document describing your lending complaint)

Notario Fraud

Type of services provided

Elder Financial Abuse

If you are a mandatory reporter and observe or suspect mistreatment (abuse, neglect, or exploitation) of an at-risk elder or adult with an I/DD, you must make a report with law enforcement within 24 hours by calling 720.913.2000.

Fair Housing

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What services are you interested in?

Company Information

Name of Company

Company Street

Company City

Company State

Company Postal Code

Company Country

Company Website

Company Phone

Do you have a contact at the company you would like to provide?

Company Contact First Name

Company Contact Last Name

Desired Resolution

By filing this complaint, I give OFE/CFPD authority to act on my behalf *

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Please upload documents supporting your concerns (e.g. paystubs, letters)

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