Order: Life in Lansing required to pay back wages

7/28/2019 Order: Life in Lansing required to pay back wages

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WAGE & HOUR DIVISIONDETERMINATION SUMMARY ACT 390

CLAIMNUMBER: 171217INVESTIGATOR : Krist ine Reigler

CLAIMANTN AME & ADDRESS : EMPLOYER LEGAL IDENTITY & ADDRESS :

Life in Lansing LLC5700 Aurelius Rd. #300

Lansing, MI 48911CC : CC :Life in Lansing LLCP.O. Box 21055Lansing, MI 48909

D-1/VIOLATION STATEMENT

SECTIONS VIOLATED 2(1), 5(1), 9(3) TOTAL AMOUNT ORDERED DUE $2,915.00

W AGES DUE $2,915.00 E ARNED July 15, 2012 TO September 30, 2012

FRINGE BENEFITS DUE N/A, N/A E ARNED N/A TO N/A

10% P ER ANNUM PENALTY OF $0.79 PER D AY COMMENCING November 7, 2012

CIVILPENALTY OF $1,000.00 (50% of unpaid wages and fringe benefits not to exceed $1,000.00)

CIVILPENALTY OF $300.00 (Section 9 violations $300.00)

D ATE (S) P ARTIES WERE ADVISED OF FINDINGS: BOTH PARTIES WERE ADVISED OF THE FINDINGS BY LETTER DATEDM ARCH 1, 2013.

EMPLOYER PLACE OF B ANKING: MICHIGAN STATE UNIVERSITY FEDERAL CREDIT UNION

SUMMARY OF COMPLAINT

D ATE COMPLAINT WAS OPENED : November 2, 2012

OCCUPATION : Video Editor/Videographer

W AGE AGREEMENT : $10/hr. throug h 7/31/12; $850.00 semi-monthl y effect ive 8/1/12

N ATURE /AMOUNT CLAIMED: $2,915.00 wages

PERIOD CLAIMED: Jul y 15, 2012 thro ugh September 30, 2012

EMPLOYER LEGAL IDENTITY

SOURCE : CORPORATION AND SECURITIES {CID #E0037M} {INCORPORATION D ATE : 11-19-2007} {L AST ANNUALREPORT : 2012} {STATUS : ACTIVE} {RESIDENT AGENT : MARCUS FRANCOEUR }COUNTY CLERKTREASURY /S ALES T AX LICENSE #OTHER :

IS EMPLOYER STILL INBUSINESS ? YES NO

B ASIS FOR INDIVIDUALLIABILITY/CO-EMPLOYER : Business is active and o perating.

Received3/21/2013


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vs. Life in Lansing LLCKristine Reigler, Investigator Page 2

SUMMARY OF INVESTIGATION

RECORDS REQUESTS (attach letters, reports, notices, etc. ):NOTIFICATION D ATE : November 7, 2012 NOTICE TO PRODUCE D ATE : January 16, 2013D ATE (S ) OF OTHER ATTEMPTS : M ARCH 1, 2013

FINDINGS FROM INVESTIGATION (review of records/interview of witnesses ):On October 26, 2012, claimant filed a wage complaint alleging hourly wages due in the amount of $315.00 earnedduring the period of July 15, 2012 through July 31, 2012; salary due in the amount of $2,600.00 earned during theperiod of August 1, 2012 through September 30, 2012. The employer was notified of the allegations of thecomplaint by letter dated November 7, 2012. On January 16, 2013, a Notice to Produce Records was sent to theemployer. To date, the employer has failed to respond to the allegations of this complaint.

Claimant was employed by this employer as Video Editor/Videographer from July 15, 2012 through September 30,2012. Claimant was paid an hourly wage of $10.00 through July 31, 2012. During the period of July 15, 2012through July 31, 2012, worked 31.5 hours, earning wages in the amount of $315.00 (31.5 hrs. x $10/hr.).

Beginning August 1, 2012, claimants wage agreement changed to a semi-monthly salary of $850.00. Claimantworked four complete pay periods during the period of August 1, 2012 through September 30, 2012 (8/1/12-8/15/12; 8/16/12-8/31/12; 9/1/12-9/15/12; 9/16/12-9/30/12), earning wages in the amount of $3,400.

On August 15, 2012, employer issued check #1354 to claimant in the amount of $283.00. This check was not ableto be cashed due not sufficient funds. On September 3, 2012, employer issued check #1388 to claimant in theamount of $699.71. This check was not able to be cashed due to not sufficient funds. On September 17, 2012,employer issued a check in the amount of $699.70. Claimant has not been able to receive funds for this check.On September 27, 2012, claimant did receive $800.00 from employer. Wages are found due to claimant in theamount of $2,915.00.

$ 315.00 wages earned 7/15/12-7/31/12+$3,400.00 wages earned 8/1/12-9/30/12$3,715.00 total wages earned$ 800.00 wages paid$2,915.00 DUE

CONCLUSION : Wages are found due to claimant in the amount of $2,915.00 gross.

_____________________________________________________ KRISTINE REIGLER , INVESTIGATOR D ATE

_____________________________________________________ S IGNATURE OF SUPERVISOR D ATE

ATTACHMENTS (descriptive list ): Limited Liability Company Details; Notification letter dated November 7,2012; Notice to Produce Records dated January 16, 2013; Copy of NSF checks 1354, 1388 and 1361;Copy of findings letter dated March 1, 2013

Jill Hookey2013.05.20 14:02:19 -04'00'


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ted Liability Company Details

/www.dleg.state.mi.us/bcs_corp/dt_llc.asp?id_nbr=E0037M&name_entity=LIFE%20IN%20LANSING%20LLC[1/15/2013 12:18:03 PM]

higan.gov Home LARA Home | Sitemap | Contact | Online Services | Agencies

Searched for: LIFE IN LANSING LLC

ID Num: E0037M

Name: LIFE IN LANSING LLC

Type: Domestic Limited Liability Company

Resident Agent: MARCUS FRANCOEUR

Registered Office Address: 5700 AURELIUS RD #300 LANSING MI 48911

Mailing/Office Address:

Formation/Qualification Date: 11-19-2007

Jurisdiction of Origin: MICHIGAN

Managed by: Members

Status: ACTIVE Date: Present

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Michigan.gov Home | LARA Home | LARA Contact | State Web SitesPrivacy Policy | Link Policy | Accessibility Policy | Security Policy

Copyright 2001- 2013 State of Michigan


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MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRSMICHIGAN OCCUPATIONAL SAFETY & HEALTH ADMINISTRATION

Mailing Address: WAGE & HOUR DIVISION Street Address:P.O. Box 30476 7150 Harris DriveLansing, MI 48909-7976 Dimondale, MI 48821Telephone: 517.322.1825Facsimile: 517.322.6352

NOTICE TO PRODUCE RECORDS

AUTHORITY: Act 390, Pub lic Ac ts o f 1978 , As Amended

COMPLETION: MandatoryPENALTY: Misdemeanor

LARA is an equal opportunity employer/program. Auxiliary aids, services, and other

reasonable accommodations are available, upon request, to individuals with disabilities.Call 517.322.1825 to make your needs known to this agency.

Claim Number:

Claimant Name:

Business Name: Life in Lansing LLCLegal Identity:

Attention: Address:

Life in Lansing LLC,

5700 Aurelius Rd., #300Lansing, MI 48911

On November 7, 2012 notification of the above-referenced complaint was mailed requesting a statement of any disagreement with the claim and submission of copies of time records, payroll records including grossearnings & itemization of deductions, written agreements or written policies, commission statements,canceled checks, or other information necessary to resolve the claim. The requested records were notprovided.

Section 9 of the Payment of Wages and Fringe Benefits Ac t, 1978 PA 390, MCL 408.471 et seq., requiresan employer to maintain a record for each employee to include the employee's name, birth date, occupationor classification in which employed, total basic rate of pay, total hours worked each pay period, total wagespaid each pay period and a separate itemization of deductions and to make these records available for inspection by the department. The department also has authority pursuant to Section 11(5), to require theproduction of any records or documents it considers relevant or material to an investigation.

NOTICE

It is therefore directed that copies of the following records be submitted to this office no later than January 30,2012:

daily time records, payroll records, canceled checks, written agreements and any other information used to determine your payroll for fromJuly 15, 2012 to September 30, 2012.

FAILURE TO PROVIDE THE REQUESTED RECORDS CONSTITUTES A VIOLATION OF THE PAYMENTOF WAGES AND FRINGE BENEFITS ACT AND MAY RESULT IN A CIVIL PENALTY OF $300.00. Arecords or information you submit will be considered in the department's decision. Absent a response, theinvestigation will be concluded and a determination issued based upon evidence received by the department.The determination may include an order requiring payment of wages, fringe benefits, an interest penalty,exemplary damages of not more than twice the amount found due, a civil penalty not to exceed $1,000.00 andup to a $1,000.00 penalty for failing to provide records to the department during the investigation.Department Representative Kristine Reigler Investigator / (517) 636-6261 Date

1/16/13

Cc: Life in Lansing LLC,

P.O. Box 21055Lansing, MI 48909


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From Claimant


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From Claimant


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From Claimant


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From Claimant


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From Claimant


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V. LIFE IN LANSING LLCINVESTIGATIVE FINDINGS

On October 26, 2012, claimant filed a wage complaint alleging hourly wages due in theamount of $315.00 earned during the period of July 15, 2012 through July 31, 2012;

salary due in the amount of $2,600.00 earned during the period of August 1, 2012through September 30, 2012. The employer was notified of the allegations of thecomplaint by letter dated November 7, 2012. On January 16, 2013, a Notice to ProduceRecords was sent to the employer. To date, the employer has failed to respond to theallegations of this complaint.

Claimant was employed by this employer as Video Editor/Videographer from July 15,2012 through September 30, 2012. Claimant was paid an hourly wage of $10.00 throughJuly 31, 2012. During the period of July 15, 2012 through July 31, 2012, worked 31.5hours, earning wages in the amount of $315.00 (31.5 hrs. x $10/hr.).

Beginning August 1, 2012, claimants wage agreement changed to a semi-monthly salaryof $850.00. Claimant worked four complete pay periods during the period of August 1,2012 through September 30, 2012 (8/1/12-8/15/12; 8/16/12-8/31/12; 9/1/12-9/15/12;9/16/12-9/30/12), earning wages in the amount of $3,400.

On August 15, 2012, employer issued check #1354 to claimant in the amount of $283.00.This check was not able to be cashed due not sufficient funds. On September 3, 2012,employer issued check #1388 to claimant in the amount of $699.71. This check was notable to be cashed due to not sufficient funds. On September 17, 2012, employer issued a check in the amount of $699.70. Claimant has not been able to receive funds for thischeck. On September 27, 2012, claimant did receive $800.00 from employer. Wagesare found due to claimant in the amount of $2,915.00.

$ 315.00 wages earned 7/15/12-7/31/12+$3,400.00 wages earned 8/1/12-9/30/12$3,715.00 total wages earned $ 800.00 wages paid $2,915.00 DUE


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S TATE OF MICHIGANRICK SNYDER

GOVERNORDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

MICHIGAN OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATIONMARTHA B. YODER

DIRECTOR

STEVE ARWOODDIRECTOR

LARA is an equal opportunity employer/program.Auxiliary aids, services and other reasonable accommodations are available, upon request, to individuals with disabilities.

WAGE & HOUR DIVISIONP.O. BOX 30476 x LANSING, MICHIGAN 48909-7976

www.michigan.gov/wagehour x (517) 322-1825 x FAX (517) 322-6352

March 1, 2013

Life in Lansing LLC

5700 Aurelius, Ste. 300Lansing, MI 48911

Dear

Re: vs. Life in Lansing LLC,

This letter is to advise you of the findings in the above referenced case.

The investigation has disclosed that $2,915.00 is due to for wages earned during the period from J uly 15, 2012 to September 30, 2012. The attached sheet provides a detailed explanation on how this figure wasobtained and calculated.

If you agree with the findings, please submit a check or money order for $2,915.00 payable to to thisoffice as soon as possible, but no later than March 15, 2013.

If you disagree with the findings and do not submit payment, a departmental determination order will be issued.When the order is issued, you will receive a copy of that order in the mail which will contain instructions on how tofile an appeal. The order will be mailed to both parties, finding the money due and assess penalties in accordancewith Section 18 of 1978 PA 390, the Payment of Wages and Fringe Benefits Act, as amended, MCLA 408.471 etseq. Both parties have 14 days from the date of the determination order to file an appeal.

If voluntary payment is not made and an order is issued, penalties assessed include:x a 10 percent per annum interest penalty calculated on a daily basis in the amount of $0.79 per day

beginning November 7, 2012;x a civil penalty of half of the amount found due not to exceed $1,000.00 in the amount of $1,000.00; andx a civil penalty in the amount of $300 for failing to provide the requested records during the investigation.

A copy of Act 390 and administrative rules may be obtained at www.michigan.gov/wagehour or you may contact thedivisions main office at (517) 322-1825 to request a copy be mailed. You may contact me at (517) 636-6261 if youhave any questions or concerns.

Sincerely,

Kristine Reigler, Investigator

cc: Life in Lansing LLC



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V. LIFE IN LANSING LLCINVESTIGATIVE FINDINGS

On October 26, 2012, claimant filed a wage complaint alleging hourly wages due in theamount of $315.00 earned during the period of July 15, 2012 through July 31, 2012;

salary due in the amount of $2,600.00 earned during the period of August 1, 2012through September 30, 2012. The employer was notified of the allegations of thecomplaint by letter dated November 7, 2012. On January 16, 2013, a Notice to ProduceRecords was sent to the employer. To date, the employer has failed to respond to theallegations of this complaint.

Claimant was employed by this employer as Video Editor/Videographer from July 15,2012 through September 30, 2012. Claimant was paid an hourly wage of $10.00 throughJuly 31, 2012. During the period of July 15, 2012 through July 31, 2012, worked 31.5hours, earning wages in the amount of $315.00 (31.5 hrs. x $10/hr.).

Beginning August 1, 2012, claimants wage agreement changed to a semi-monthly salaryof $850.00. Claimant worked four complete pay periods during the period of August 1,2012 through September 30, 2012 (8/1/12-8/15/12; 8/16/12-8/31/12; 9/1/12-9/15/12;9/16/12-9/30/12), earning wages in the amount of $3,400.

On August 15, 2012, employer issued check #1354 to claimant in the amount of $283.00.This check was not able to be cashed due not sufficient funds. On September 3, 2012,employer issued check #1388 to claimant in the amount of $699.71. This check was notable to be cashed due to not sufficient funds. On September 17, 2012, employer issued a check in the amount of $699.70. Claimant has not been able to receive funds for thischeck. On September 27, 2012, claimant did receive $800.00 from employer. Wagesare found due to claimant in the amount of $2,915.00.

$ 315.00 wages earned 7/15/12-7/31/12+$3,400.00 wages earned 8/1/12-9/30/12$3,715.00 total wages earned $ 800.00 wages paid $2,915.00 DUE


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MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRSMICHIGAN OCCUPATIONAL SAFETY & HEALTH ADMINISTRATION

Mailing Address: WAGE & HOUR DIVISION Street Address:P.O. Box 30476 7150 Harris DriveLansing, MI 48909-7976 Dimondale, MI 48821Telephone: 517.322.1825Facsimile: 517.322.6352

NOTICE TO PRODUCE RECORDS

AUTHORITY: Act 390, Pub lic Ac ts o f 1978 , As Amended

COMP LETION: MandatoryPENALTY: Misdemeanor

LARA is an equal opportunity employer/program. Auxiliary aids, services, and other

reasonable accommodations are available, upon request, to individuals with disabilities.Call 517.322.1825 to make your needs known to this agency.

Claim Number: 171217

Claimant Name:

Business Name: Life in Lansing LLCLegal Identity:

Attention:Address:

Life in Lansing LLC,

5700 Aurelius Rd., #300Lansing, MI 48911

On November 7, 2012 notification of the above-referenced complaint was mailed requesting a statement of any disagreement with the claim and submission of copies of time records, payroll records including grossearnings & itemization of deductions, written agreements or written policies, commission statements,canceled checks, or other information necessary to resolve the claim. The requested records were notprovided.

Section 9 of the Payment of Wages and Fringe Benefits Ac t, 1978 PA 390, MCL 408.471 et seq., requiresan employer to maintain a record for each employee to include the employee's name, birth date, occupationor classification in which employed, total basic rate of pay, total hours worked each pay period, total wagespaid each pay period and a separate itemization of deductions and to make these records available forinspection by the department. The department also has authority pursuant to Section 11(5), to require theproduction of any records or documents it considers relevant or material to an investigation.

NOTICE

It is therefore directed that copies of the following records be submitted to this office no later than J anuary 30,2012:

daily time records, payroll records, canceled checks, written agreements and any otherinformation used to determine your payroll for from

J uly 15, 2012 to September 30, 2012.

FAILURE TO PROVIDE THE REQUESTED RECORDS CONSTITUTES A VIOLATION OF THE PAYMENTOF WAGES AND FRINGE BENEFITS ACT AND MAY RESULT IN A CIVIL PENALTY OF $300.00. Arecords or information you submit will be considered in the department's decision. Absent a response, theinvestigation will be concluded and a determination issued based upon evidence received by the department.The determination may include an order requiring payment of wages, fringe benefits, an interest penalty,exemplary damages of not more than twice the amount found due, a civil penalty not to exceed $1,000.00 andup to a $1,000.00 penalty for failing to provide records to the department during the investigation.Department Representative Kristine Reigler Investigator / (517) 636-6261 Date

1/16/13

Cc: Life in Lansing LLC,



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ted Liability Company Details

/www.dleg.state.mi.us/bcs_corp/dt_llc.asp?id_nbr=E0037M&name_entity=LIFE%20IN%20LANSING%20LLC[1/15/2013 12:18:03 PM]

higan.gov Home LARA Home | Sitemap | Contact | Online Services | Agencies

Searched for: LIFE IN LANSING LLC

ID Num: E0037M

Name: LIFE IN LANSING LLC

Type: Domestic Limited Liability Company

Resident Agent: MARCUS FRANCOEUR

Registered Office Address: 5700 AURELIUS RD #300 LANSING MI 48911

Mailing/Office Address:

Formation/Qualification Date: 11-19-2007

Jurisdiction of Origin: MICHIGAN

Managed by: Members

Status: ACTIVE Date: Present

View Document Images

Return to Search New Search

Michigan.gov Home | LARA Home | LARA Contact | State Web SitesPrivacy Policy | Link Policy | Accessibility Policy | Security Policy

Copyright 2001- 2013 State of Michigan


18/31

1

Wright, Kim (LARA)

From: Reigler, Kristine (LARA)Sent: Tuesday, December 18, 2012 8:14 AMTo: Reigler, Kristine (LARA)Subject: v. Life in Lansing INVESTIGATION REPORT

Claimant called obtain status update . Investigator advised employer has not responded and requestedclaimant provide copies of pay stubs or any other information he has to help substantiate his claim.

Kristine Reigler, InvestigatorMichigan Department of Licensing and Regulatory AffairsMichigan Occupational Safety and Health AdministrationWage & Hour Division7150 Harris Drive l PO Box 30476 l Lansing, MI 48909Direct: (517) 636-6261Fax: (517) 322-6352

Information provided in this response may contain legal information. Legal information is not the same as legal advice the application of law to an individual'sspecific circumstances. The division will do its best to provide you with information that is accurate and useful, but it is recommended you consult a lawyer if youwant professional assurance the information, and your interpretation of it, is appropriate to your particular situation.

The information contained in this transmission is intended only for the use of the individual or entity named above, and may contain information that is privileged, confidential,and exempt from disclosure under applicable laws. If you are not the intended recipient, you are notified dissemination, distribution, or duplication is strictly prohibited. If youhave received this message in error, please delete it from your system and notify the sender.


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Wright, Kim (LARA)

From:Sent: Thursday, November 08, 2012 12:41 PMTo: Reigler, Kristine (LARA)Subject: Vs Life In Lansing - Correction needed in amount paid on

document received today Attachments: wage_complaint_form_7816202.pdf; Scan of letter receved Nov 8th with mistake of payment

recieved.jpeg

Dear Kristine Reigler,

Thank you for taking on my case. I received a letter today confirming this and something on it concerned me.Everything on the amount and wages section is correct except that they didn't pay me $80.00, they paid me$800.00. Just to make sure, I went back and looked at the original complaint form I submitted and it does say$800.00 . Was this just a misprint on the letter sent to me or was it also on the letter sent to life in lansing? I justreally would like to avoid any confusion especially on the other end of things. I understand the offices areclosed today and other cases need to come first, but if you could clarify this one aspect of the investigation Iwould be extremely grateful. I will include a copy of the original complaint form as well as a copy of the letter I

received today with the correction highlighted.Thanks so much, I look forward to hearing from you.


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EMPLOYMENT WAGE COMPLAINTMichigan Department of Licensing and Regulatory AffairsMichigan Occupational Safety and Health AdministrationWage & Hour Division

IMPORTANT: By filing th is claim wi th the Wage and Hour Divisio n, you are electin g a remedy which may prevent youfrom pursuing th is claim elsewhere, including civil court.

EMPLOYEE INFORMATION Please print

ADDRESS (STREET NUMBER AND NAME):

CITY, STATE, ZIP: COUNTY:

BIRTH DATE:

5700 Aureliu s Road, Suit e 300

Lansing MI 48911

EMPLOYER INFORMATION

Life In Lansing

5700 Aureliu s Road, Suit e 300CITY, STATE, ZIP:Lansin g, MI 48911

EMAIL OR WEBSITE ADDRESS OF EMPLOYER (IF KNOWN):

www.lifeinlansing.com TELEPHONE NUMBER:

LIST THE APPROXIMATE NUMBER OF EMPLOYEES:10-12

NAME OF PERSON IN CHARGE OF DAY-TO-DAY OPERATIONS:

07/15/2012Start date of employment (Month/Day/Year): 09/30/2012Employment Status:

LIST YOUR RATE OF PAY: PER HOUR$

SALARY PIECE RATE/OTHER

How often were you paid?

MONTHLY

Video Editor/Videographer

LAST 4 NUMBERS OF SOCIAL SECURITYNUMBER:

LAST NAME, FIRST NAME, MIDDLE INITIAL

EMAIL ADDRESS: PRIMARY TELEPHONE NUMBER: DAYTIME TELEPHONE NUMBER:

ADDRESS WHERE YOU WORKED (STREET NUMBER AND NAME):

CITY, STATE, ZIP: COUNTY:

AUTHORITY: ACT 390, PUBLIC ACTS OF 1978, AS AMENDEDACT 154, PUBLIC ACTS OF 1964, AS AMENDED

COMPLETION: VOLUNTARYPENALTY: NONE

BUSINESS NAME:

BUSINESS ADDRESS (STREET NUMBER AND NAME):

COUNTY

Last date worked (Month/Day/Year):

QUIT DISCHARGED STILL EMPLOYEDXCOMMISSION$ $$

If salaried, how many days/hours were you requir edto wor k each week or pay period?

WEEKLY SEMI-MONTHLYBI-WEEKLY

850.00

5d

Ingham

Ingham

X Mr. Ms. Mrs. Miss. Dr.

PROVIDE A COPY OF YOUR CHECK STUB.What was/is your job title?

Was Your Employment Governed by One or More Employers? If so, list below the addition al employer's name, address, city,state, zip code, and telephone number or attach an addiitio nal sheet listing t he information.

Mailing Address:P.O. Box 30476Lansing, MI 48909-7976

Street Address:7150 Harris DriveDimondale, MI 48821

Website: www.michigan.gov/wagehour

LARA is an equal opportunity employer/program. Auxilliary aids,services and other reasonable accommodations are available,upon request, to individuals with disabilities for the purpose of accessibility under the state and federal law. Please call

CLAIM NUMBER:

Telephone: 517.322.1825 Facsimile: 517.322.6352

517.322.1825 to make your needs known to this agency.

CONTACT INFORMATION FOR SOMEONE WHO WILL ALWAYS KNOW HOW TO REACH YOU.

TYPE OF BUSINESS:

711 Performing Arts, Sports,

FAX NUMBER:


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2915.00

If claiming fringe benefits, was a written policy or contract in effect during your employment?If yes, please provide a copy of the written policy or contract.

Was your employment covered by a union contract? If yes, please submit a copy of the contract.

THE CLAIM WILL BE RETURNED IF A CLAIM AMOUNT AND A CLAIM PERIOD ARE NOT PROVIDED.

Your Reason fo r Filing this Claim

AmountClaimed

Period Claimed Calculate Amount Claimed(Attach additional sheets if necessary)Month/Day/Year Month/Day/Year

Hourly WagesSalaryCommissions

Unauthorized

MINIMUM WAGE

Vacation Pay

Sick Pay

Expense

Holiday Pay

Paid Time Off

Bonus

Piece Rate/Other

TOTAL GROSS (before tax deduct ions ) AMOUNT CLAIMED

to

PLEASE ANSWER THE FOLLOWING

Does the business make more than $500,000/year or transport goods outside of Michigan?

YES NO

X

315.00

2600.00

07/31/2012

/ /

08/01/2012 09/30/2012

/ / / /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

/ /

Pay Periods (before taxes):

07/15/2012-07/31/2012 -->$315.00hours worked: 31.5(This pay period was hourly)

(all following pay periods were Salary(($850.00 every 2 weeks)) but stillkept tract of hours)

08/01/2012-08/15/2012 -->$850.00hours worked: 58.5

08/16/2012-08/31/2012 -->$850.00hours worked:97.5

09/01/2012-09/15/2012 -->$850.00hours worked: 71.5

09/16/2012-09/30/2012-->$850.00hours worked: 88

___ ___ ___ ___ ___ ___ _____ ___ ___ ___ ___ _ _ TOTAL AMOUNT (before taxes)=$3715.00total hours worked: 347

___ ___ ___ ___ ___ _____ ___ ___ ___ ___ ___ _ _ was paid $800.00 on 9/27/2012

$3715.00

-$800.00=$2,915.00 Amount owed before taxes

CERTIFICATION: I certify that to the best of my knowledge and belief, this is a true statement of wages and/or fringe benefits due me. I willinform the department if any of the following occur: Change of name, address, and/or telephone number for myself and/or employer, or a direct

Filing this c omplaint does not guarantee payment or a find ing in your f avor.

(Provide list of commissions)

Deductions

Reimbursement(Provide list of expenses)

OVERTIME

X

X

Have you filed a law suit against the employer on the issues of this claim? X

Signature of Complainant: DATE:

(List type of bonus)

FRINGE BENEFITS(Provide written policy or contract)

WAGES

payment or settlement of the claim.

Are you filing a complaint for pay stubs or wage statements you did not receive?

XIf yes, please list dates you did not receive a pay stub or wage statement

08/16/2012-08/31/2012 - no pay stub09/01/2012-09/15/2012 - no pay s tub

Please provide docum entation to su bstantiate your claim, for example, pay stubs, time sheets, written poli cies and ect.

YES NO

7/15/2012


26/31


27/31


28/31


29/31


30/31


31/31

Documents

Order: Life in Lansing required to pay back wages