Republic of the Philippines

Department of Labor and Employment

Region 7
Cebu City

_____________________ and/or
_____________________,
Complainant/s Date: _________________

-versus – NLRC-Region 7 CASE NO. _______________________

_____________________ and/or
_____________________
Respondent/s
x-----------------------------------------------x

COMPLAINT

Complaint/s, by counsel, respectfully state/s, that:

1. Name of complainant: _____________________________ Sex: ____ Age: ____ Status: ___
2. Dependent of Complainant/s: (M) _______ (F) _______
3. Address:___________________________________________________________________
_____________________________________________________Zip Code: ____________

4. Name of Respondent Company: ________________________________________________

5. Address:___________________________________________________________________
_____________________________________________________ Zip Code: ____________
6. Represented by: Owner ( ) Manager ( ) President ( ):___________________________
7. Nature of Business: ______________________ Number of workers: ___________________
Date Employed: ____________________ Date Dismissed: __________________________
8. Nature of work/position: _____________________ Work Schedule: ___________________
Place of Work: ______________________________________________________________
9. Salary Rate: _____________________ Frequency of Payment: _______________________
10. Are you a union member? ( ) Yes ( ) No
Name of Union: _____________________________________________________________
11. Is there an existing CBA? ( ) Yes ( ) No
12. Have you filed any similar case elsewhere? ( ) Yes ( ) No
If Yes, Where? ____________________________________________________________
…………………………………………………………………………………………..
This portion is to be filled up by the Complaint Officer, unless complainant/s is with legal counsel
CAUSE OF ACTION

A. Illegal Dismissal F. Illegal Deduction ( )

ACTUAL ( ) Specify: __________________________
CONSTRUCTIVE ( ) _________________________________
B. Illegal Suspension ( ) _________________________________
C. Illegal lay-off ( ) G. Unfair Labor Practice ( )
D. Regularization ( ) Specify: ___________________________
E. Underpayment ( ) Non-payment ( ) __________________________________
1. Salaries/Wages ( ) __________________________________
2. Overtime Pay ( ) H. Damages
3. Holiday Pay ( ) Moral and Exemplary ( )
4. Premium for Actual ( )
Holiday Pay ( ) I. Attorney’s Fees ( )
Rest Day ( ) J. Others: Specify: ____________________
5. Service Incentive Leave ( ) __________________________________
6. 13th month pay ( ) __________________________________
7. Separation Pay ( ) __________________________________
8. Retirement Benefits ( ) __________________________________

(See back page)

 R E L I E F

Complainant/s pray for the following:

A. Reinstatement ---------------------------- ( ) and
B. Payment of (specify)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Other relief a just and equitable under the premises are likewise prayed for.
Done in Quezon City this __________ day of ____________________. 20 __.

____________________________________ _____________________________________
Complainant (2) Complainant (1)

Address:_____________________________
____________________________________
____________________________________
_______________ Zip code: ____________
Date Employed: ______________________
Date Dismissed: ______________________
Position: ____________________________
Salary Rate: _________________________
_____________________________________
Counsel for complainant/s
Address: _____________________________
_____________________________________
___________________ Zip Code: _________
PTR No.: _____________________________
IBP No.: _____________________________

VERIFICATION

I / We __________________________________, having been duly sworn to, (jointly and

severally, shall subscribe and be sworn to) in accordance with law, hereby depose ad state that:

I / We am/are the complainant/s in the above-entitled case;

I / We have read the contents hereof and declare the same to be true to the best of
my/own knowledge and belief.

CERTIFICATION OF NON-FORUM SHOPPING

This is to certify that I / We have not filed any similar case with any other Court, Quasi-
Judicial Court or government agency.

____________________________________ _____________________________________
Complainant (2) Complainant (1)

SUBSCRIBED AND SWORN to before me this _____ day of ____________________,

Quezon City, affiant/s exhibiting to me his/her/their Community Tax Certificate No./s
_________________ Issued on ____________________ at ________________________.

Prepared by: ________________

Complaint Officer

Date:____________________

_______________________
Administering Officer