Form Ls 11 - Letter Of Representation - New York State - Department Of Labor printable pdf download

Form Ls 11 - Letter Of Representation - New York State - Department Of Labor

Division of Labor Standards

Letter of Representation

Fill in each item if you are representing an employer or complainant in a Labor

Standards matter.

Date: ____________________________________

Case File ID or Order to Comply Number: _________________________________________

Client/Member Represented (check one):

Employer

Complainant/Claimant

Client/Member Name: _________________________________________________________

Client Business Name: ________________________________________________________

Subject of Client’s Claim (e.g. minimum wage, overtime etc.):

___________________________________________________________________________

Representative Information (all fields must be completed)

Name: _____________________________________________________________________

Organization/Firm Name: ______________________________________________________

Signature: __________________________________________________________________

Title: _______________________________________________________________________

Choose One:

Attorney

Advocate

Accountant

Other: __________________

Address: ___________________________________________________________________

Telephone: __________________________

Fax: _________________________________

Email: ______________________________________________________________________

Are you being compensated by the claimant?

Yes

Client/Member Authorization: I authorize the above named individual or organization to

represent me in matters involving my complaint/claim. You have my permission to

communicate or share information with my representative as necessary.

Client/Member Signature: ______________________________________________________

LS 11 (10/16)

Form Ls 11 - Letter Of Representation - New York State - Department Of Labor