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The Board of License Commissioners and the Town Human Rights Director shall be authorized to establish regulations or administrative procedures and to take any and all actions reasonable and necessary to further the purposes of this Bylaw or to obtain compliance with this Bylaw.
The Town Human Rights Director and the Police Department shall have the power to investigate violations of Section D of this Bylaw, and, to the extent consistent with law, with Section E and F of this Bylaw, pursuant to their own initiative or upon receipt of a report or complaint filed by an Employee or any other person.
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First Name
Last Name
Email Address
Date of Birth
Date of Birth
Type of Work Performed*
Location of Employment*
Employer or Company Name
Employer or Company Phone Number
Contact Person
Against whom the Wage & Tip Theft Claim is filed
Employer or Company Address
Date Hired
Date Hired
Are you still employed by the named employer? *
1. Yes
2. No
If your answer was no, what was the last day you worked?
If your answer was no, what was the last day you worked?
Was your terminiation:
1. Voluntary
2. Involuntary
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Wage & Theft Complaint Details

1. Was there a written contract of employment between you and your employer?
1. Yes, I will attach it in the next step
2. No
Please upload a PDF of your written employment contract
2. What was your regular payday to be?
3. How did you receive your wages? *
(Cash, Check, Direct Deposit, Other)
4. What was the latest rate of pay agreed upon between you and the named employer?
Please indicate and explain whether pay was hourly, weekly, or other.
5. What are the TOTAL wages claimed by you? *
Please explain in detail and include the total amount due to you and why you believe it is owed. Failure to provide detailed information in the space provided above may make it impossible to pursue this claim on your behalf.
6. State employer's reason for refusal of payment*
7. Have any deductions been made without your written agreement?
If Yes, please explain.
8. Do you owe any money to the named employer for any reason?*
If yes, please explain
9. Are you covered under a Collective Bargaining Agreement?
1. Yes
2. No
If you answered yes, list the name and address of the union you belong to.
Once we receive your Wage Complaint form, we will log it in and assign it to an Investigator from the Town.
NOTE: I hereby certify, by typing my name below, that to the best of my knowledge and belief, this is a true statement of facts relating to the above claim of unpaid wages.
Signature of Claimant
Type your full name
Date of Complaint
Date of Complaint
Signature of Parent or Guardian if Claimant is under 18 years of age
Next Steps
A representative from the Town of Amherst will contact you for any further information.
Please notify the Town by calling (413) 259-3009 in the event that you are paid before the Town contacts you.
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program

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