Legal Arizona Workers Act

This complaint form is prescribed by the Arizona Attorney General’s Office pursuant to Arizona Revised Statutes §§ 23-212(B) and 23-212.01(B). You may use this form to make a complaint either to the County Attorney of the county where an undocumented alien worker is or was employed or to the Arizona Attorney General’s Office. The final page of this form provides the address and telephone number of each County Attorney and the Arizona Attorney General’s Office. Mail the completed form to the appropriate address from the final page. If you have any question about this form, please direct your question to the office where you intend to send your completed form.
The law does not require you to use this complaint form, nor does the law prohibit anonymous complaints. However, if you submit a complaint by telephone or e-mail or if you use a different complaint form or if you use this form but refuse to provide your contact information and signature or if you make some other form of anonymous complaint, your complaint may or may not be investigated, at the discretion of the investigative agency. If you intend to submit your complaint to a County Attorney, but do not wish to use this form, you should contact that County Attorney’s office to determine how to submit your complaint.
Please complete all sections of this form that you can, using additional pages if necessary. If you do not know the requested information, write “unknown.” Do not guess or make up information.

Employer:

After December 31, 2007, the following employer hired one or more undocumented alien workers as employees and/or independent contractors:

Name of Employer:(Required)

Type of Business:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Employer's Phone:(Required)

Names of managers, supervisors, or others who are familiar with employer’s hiring practices:(Required)

Does the employer have one or more business licenses?(Required)

Yes

If so, what licenses?(Required)

Undocumented Alien Worker

After December 31, 2007, the following person was hired as an employee or independent contractor by the employer named on the first page and at the time of hiring, the following person was not authorized to work in the United States:

Name:(Required)

Date Hired:(Required)

Aliases:(Required)

Physical description, identifying marks:

Home Address:(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number:(Required)

Date of Birth:(Required)

Social Security Number:

Job Description:

Address where this person works or worked for employer:(Required)

Street Address Address Line 2 City State ZIP Code

What information leads you to believe that this worker was not authorized to work in the United States?(Required)

Did the employer know that this worker was not authorized to work in the United States?(Required)

Yes

What information leads you to believe that the employer did know that this worker was not authorized to work in the United States?(Required)

Did the employer check this worker using the E-Verify system?(Required)

Yes

If so, when?(Required)

What was the result?

Did the employer check this worker using the Social Security Number Verification Service?(Required)

Yes

If so, when?(Required)

What was the result?

Did the employer complete an I-9 form for this worker?(Required)

Yes

If so, when?(Required)

Did the employer accept any false documents from this worker in the I-9 process?(Required)

Yes

Did the employer know the documents were false?(Required)

What documents were false?(Required)

What information leads you to believe that the employer knew that the documents were false?(Required)

When did you become aware of the information provided on the previous pages?(Required)

How did you become aware of the information provided on the previous pages?(Required)

Are you now an employee of the employer named on the first page?(Required)

Yes

If not, have you previously been an employee of the employer named on the first page?(Required)

Yes

If you were previously employed by the employer named on the first page, when did you start, when did you leave, why did you leave, where did you work, what positions did you hold, and who were your immediate supervisors?(Required)

My Contact Information

Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone:(Required)

Work Phone:

Cell Phone:

Email:(Required)

Signature(Required)

I hereby affirm that the information set forth on all the pages of this form is true and correct.

Date:(Required)

Form

Employer:

Undocumented Alien Worker

My Contact Information

info@pcao.pima.gov

(520) 724-5600

32 N. Stone Ave
Tucson, AZ 85701

8AM - 5PM

Closed