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Frank Nardelli Commissioner Steven Bellone Suffolk County Executive SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING CONSUMER AFFAIRS COVERED EMPLOYEE COMPLAINT FORM Living Wage Law, Suffolk County Code, Chapter 575 (2001) COMPLAINANT: TELEPHONE : ADDRESS: JOB TITLE: IMMEDIATE SUPERVISOR NAME: IMMEDIATE SUPERVISOR TITLE: COVERED EMPLOYER: ADDRESS: TELEPHONE : WORKSITE ADDRESS IF DIFFERENT FROM ABOVE: NATURE OF COMPLAINT ATTACH OTHER SHEETS DOCUMENTS AS NEEDED (Signature of Complainant) (Date) Forward to: Suffolk County Department of Labor, Licensing Consumer Affairs Local Law Compliance P.O..
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