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Paid Family Leave Deduction Complaint Form

If you believe there is an error with your current payroll deduction, raise the issue with your employer. If your employer fails to address the issue, you can file a complaint by completing the form below.

EMPLOYEE INFO

Employee Information:

Employee Name:

Employee Home Mailing Address (Street, City, State):

ZIP Code

Telephone Number:

Email:

Job Title:

EMPLOYER INFO

Employer Information:

Employer Name:

HR Director or Payroll Supervisor Name (if known)

Employer Mailing Address (Street, City, State, Zip):

Employer Phone Number:

Type of Business:

Is this your current employer?

Yes

What are your gross wages? (before taxes)

How often are you paid?

Weekly

Bi-weekly

Monthly

What is the amount of PFL payroll deduction being taken out of your paycheck?

Has this been a recurring issue? If yes, for how many pay periods?

Note Text

PLEASE NOTE: The Board will contact your employer to notify them of a possible error in the PFL deduction. The letter they will receive is informative and provides guidance on how to accurately calculate an employee’s weekly payroll deduction. The letter is not specific to your complaint.

If you would like the Board to give your employer specific information about your complaint, including identifying information, (which may assist your employer in looking into and resolving the issue), please indicate ‘YES’ below so the Board has permission to share this information with your employer.

Paid Family Leave Deduction Complaint Form

Employee Information:

Employer Information:

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