WAGE & HOUR DIVISION DETERMINATION SUMMARY ACT 390 CLAIM NUMBER: 171217 INVESTIGATOR: Kristine Reigler CLAIMANT

NAME & ADDRESS: EMPLOYER LEGAL IDENTITY & ADDRESS: Life in Lansing LLC 5700 Aurelius Rd. #300 Lansing, MI 48911 CC: Life in Lansing LLC P.O. Box 21055 Lansing, MI 48909 D-1/VIOLATION STATEMENT SECTIONS VIOLATED 2(1), 5(1), 9(3) WAGES DUE $2,915.00 FRINGE BENEFITS DUE N/A, N/A

Received 3/21/2013

CC:

TOTAL AMOUNT ORDERED DUE $2,915.00 EARNED July 15, 2012 TO September 30, 2012 EARNED N/A TO N/A

10% PER ANNUM PENALTY OF $0.79 PER DAY COMMENCING November 7, 2012 CIVIL PENALTY OF $1,000.00 (50% of unpaid wages and fringe benefits not to exceed $1,000.00) CIVIL PENALTY OF $300.00 (Section 9 violations $300.00) DATE(S) PARTIES WERE ADVISED OF FINDINGS: BOTH PARTIES WERE ADVISED OF THE FINDINGS BY LETTER DATED MARCH 1, 2013. EMPLOYER PLACE OF BANKING: MICHIGAN STATE UNIVERSITY FEDERAL CREDIT UNION SUMMARY OF COMPLAINT DATE COMPLAINT WAS OPENED: November 2, 2012 OCCUPATION: Video Editor/Videographer WAGE AGREEMENT: $10/hr. through 7/31/12; $850.00 semi-monthly effective 8/1/12 NATURE/AMOUNT CLAIMED: $2,915.00 wages PERIOD CLAIMED: July 15, 2012 through September 30, 2012 EMPLOYER LEGAL IDENTITY SOURCE: CORPORATION AND SECURITIES {CID #E0037M} {INCORPORATION DATE: 11-19-2007} {LAST ANNUAL REPORT: 2012} {STATUS: ACTIVE} {RESIDENT AGENT: MARCUS FRANCOEUR} COUNTY CLERK TREASURY/SALES TAX LICENSE # OTHER: YES NO

IS EMPLOYER STILL IN BUSINESS?

BASIS FOR INDIVIDUAL LIABILITY/CO-EMPLOYER: Business is active and operating.

vs. Life in Lansing LLC Kristine Reigler, Investigator Page 2 SUMMARY OF INVESTIGATION RECORDS REQUESTS (attach letters, reports, notices, etc.): NOTIFICATION DATE: November 7, 2012 DATE(S) OF OTHER ATTEMPTS: MARCH 1, 2013 NOTICE TO PRODUCE DATE: January 16, 2013

FINDINGS FROM INVESTIGATION (review of records/interview of witnesses): On October 26, 2012, claimant filed a wage complaint alleging hourly wages due in the amount of $315.00 earned during the period of July 15, 2012 through July 31, 2012; salary due in the amount of $2,600.00 earned during the period of August 1, 2012 through September 30, 2012. The employer was notified of the allegations of the complaint by letter dated November 7, 2012. On January 16, 2013, a Notice to Produce Records was sent to the employer. To date, the employer has failed to respond to the allegations of this complaint. Claimant was employed by this employer as Video Editor/Videographer from July 15, 2012 through September 30, 2012. Claimant was paid an hourly wage of $10.00 through July 31, 2012. During the period of July 15, 2012 through July 31, 2012, worked 31.5 hours, earning wages in the amount of $315.00 (31.5 hrs. x $10/hr.). Beginning August 1, 2012, claimants wage agreement changed to a semi-monthly salary of $850.00. Claimant worked four complete pay periods during the period of August 1, 2012 through September 30, 2012 (8/1/128/15/12; 8/16/12-8/31/12; 9/1/12-9/15/12; 9/16/12-9/30/12), earning wages in the amount of $3,400. On August 15, 2012, employer issued check #1354 to claimant in the amount of $283.00. This check was not able to be cashed due not sufficient funds. On September 3, 2012, employer issued check #1388 to claimant in the amount of $699.71. This check was not able to be cashed due to not sufficient funds. On September 17, 2012, employer issued a check in the amount of $699.70. Claimant has not been able to receive funds for this check. On September 27, 2012, claimant did receive $800.00 from employer. Wages are found due to claimant in the amount of $2,915.00. $ 315.00 wages earned 7/15/12-7/31/12 +$3,400.00 wages earned 8/1/12-9/30/12 $3,715.00 total wages earned $ 800.00 wages paid $2,915.00 DUE CONCLUSION: Wages are found due to claimant in the amount of $2,915.00 gross. DATE

_____________________________________________________ KRISTINE REIGLER, INVESTIGATOR

Jill Hookey 2013.05.20 14:02:19 -04'00'

_____________________________________________________ SIGNATURE OF SUPERVISOR DATE

ATTACHMENTS (descriptive list): Limited Liability Company Details; Notification letter dated November 7,

2012; Notice to Produce Records dated January 16, 2013; Copy of NSF checks 1354, 1388 and 1361; Copy of findings letter dated March 1, 2013

Limited Liability Company Details

Michigan.gov Home

LARA Home | Sitemap | Contact | Online Services | Agencies

Searched for: LIFE IN LANSING LLC ID Num: E0037M Name:LIFE IN LANSING LLC Type: Domestic Limited Liability Company Resident Agent: MARCUS FRANCOEUR Registered Office Address: 5700 AURELIUS RD #300 Mailing/Office Address: Formation/Qualification Date: 11- 19- 2007 Jurisdiction of Origin: MICHIGAN Managed by: Members Status: ACTIVE Date: Present LANSING MI 48911

View Document Images

Return to Search

New Search

Michigan.gov Home | LARA Home | LARA Contact | State Web Sites Privacy Policy | Link Policy | Accessibility Policy | Security Policy Copyright 2001- 2013 State of Michigan

http://www.dleg.state.mi.us/bcs_corp/dt_llc.asp?id_nbr=E0037M&name_entity=LIFE%20IN%20LANSING%20LLC[1/15/2013 12:18:03 PM]

Mailing Address: P.O. Box 30476 Lansing, MI 48909-7976 Telephone: 517.322.1825 Facsimile: 517.322.6352

MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS MICHIGAN OCCUPATIONAL SAFETY & HEALTH ADMINISTRATION WAGE & HOUR DIVISION

Street Address: 7150 Harris Drive Dimondale, MI 48821

NOTICE TO PRODUCE RECORDS

AUTHORITY: Act 390, Public Acts of 1978, As Amended COMPLETION: Mandatory PENALTY: Misdemeanor
LARA is an equal opportunity employer/program. Auxiliary aids, services, and other reasonable accommodations are available, upon request, to individuals with disabilities. Call 517.322.1825 to make your needs known to this agency.

Claim Number: Claimant Name: Business Name: Life in Lansing LLC Legal Identity: Life in Lansing LLC, Attention: Address: 5700 Aurelius Rd., #300 Lansing, MI 48911 On November 7, 2012 notification of the above-referenced complaint was mailed requesting a statement of any disagreement with the claim and submission of copies of time records, payroll records including gross earnings & itemization of deductions, written agreements or written policies, commission statements, canceled checks, or other information necessary to resolve the claim. The requested records were not provided. Section 9 of the Payment of Wages and Fringe Benefits Act, 1978 PA 390, MCL 408.471 et seq., requires an employer to maintain a record for each employee to include the employee's name, birth date, occupation or classification in which employed, total basic rate of pay, total hours worked each pay period, total wages paid each pay period and a separate itemization of deductions and to make these records available for inspection by the department. The department also has authority pursuant to Section 11(5), to require the production of any records or documents it considers relevant or material to an investigation. NOTICE It is therefore directed that copies of the following records be submitted to this office no later than January 30, 2012: daily time records, payroll records, canceled checks, written agreements and any other information used to determine your payroll for from July 15, 2012 to September 30, 2012. FAILURE TO PROVIDE THE REQUESTED RECORDS CONSTITUTES A VIOLATION OF THE PAYMENT OF WAGES AND FRINGE BENEFITS ACT AND MAY RESULT IN A CIVIL PENALTY OF $300.00. Any records or information you submit will be considered in the department's decision. Absent a response, the investigation will be concluded and a determination issued based upon evidence received by the department. The determination may include an order requiring payment of wages, fringe benefits, an interest penalty, exemplary damages of not more than twice the amount found due, a civil penalty not to exceed $1,000.00 and up to a $1,000.00 penalty for failing to provide records to the department during the investigation. Department Representative Kristine Reigler Investigator / (517) 636-6261 Date 1/16/13 Cc: Life in Lansing LLC, P.O. Box 21055 Lansing, MI 48909

From Claimant

From Claimant

From Claimant

From Claimant

From Claimant

F
C CC

C
F
C

FF

ar i in an in C Fran o r r li t an in ar ar t r Fran o n a i r i in an in in in t at C in t a o i atta r to r n t n t ro i or a a a r or or a tail arn rin t lanation on o t i a a l to t n a i rio rom r a to t i

nt

nt

i l tt r i to a in l o tain o i

o o t

ti ation a i lo to t m r an al lat

o a r it t in in a oon a o i l o

l a mit a t no lat r t an ar

or mon

i a r it t n t or r i i il an a al or it tion o ot arti a ol ntar x a x x

in in an o not mit a m nt a artm ntal t rmination or r ill i o ill r i a o o t at or r in t mail i ill ontain in tr tion on o to r ill mail to ot arti in in t mon an a nalti in a or an t a am n C t t a m nt o a an Frin n it a rom t at o t t rmination or r to il an a al in l a i t in t amo nt o in r an ti ation onta t t i o a

a m nt i not ma an an or r i i nalti a r nt r ann m int r t nalt al lat on a ail innin o m r a i il nalt o al o t amo nt o n not to a i il nalt in t amo nt o or ailin to ro i t r r l ma to r o tain ta o at mail mi

in t amo nt o r or rin t

o o t an a mini trati i i ion main o i at a an tion or on rn in r l i l r n t olt

iliar ai r i an ot

i an o a o r or o ma o ma onta t m at

ri tin

ti ator i in an in Fran o o an in ar C r i nt nt

n a Cotton oo

i an al o ort nit m lo r ro ram r r a ona l a ommo ation ar a aila l on r x o rx C xF

t to in i i

al

it

i a iliti

mi

i an o

V. LIFE IN LANSING LLC INVESTIGATIVE FINDINGS On October 26, 2012, claimant filed a wage complaint alleging hourly wages due in the amount of $315.00 earned during the period of July 15, 2012 through July 31, 2012; salary due in the amount of $2,600.00 earned during the period of August 1, 2012 through September 30, 2012. The employer was notified of the allegations of the complaint by letter dated November 7, 2012. On January 16, 2013, a Notice to Produce Records was sent to the employer. To date, the employer has failed to respond to the allegations of this complaint. Claimant was employed by this employer as Video Editor/Videographer from July 15, 2012 through September 30, 2012. Claimant was paid an hourly wage of $10.00 through July 31, 2012. During the period of July 15, 2012 through July 31, 2012, worked 31.5 hours, earning wages in the amount of $315.00 (31.5 hrs. x $10/hr.). Beginning August 1, 2012, claimants wage agreement changed to a semi-monthly salary of $850.00. Claimant worked four complete pay periods during the period of August 1, 2012 through September 30, 2012 (8/1/12-8/15/12; 8/16/12-8/31/12; 9/1/12-9/15/12; 9/16/12-9/30/12), earning wages in the amount of $3,400. On August 15, 2012, employer issued check #1354 to claimant in the amount of $283.00. This check was not able to be cashed due not sufficient funds. On September 3, 2012, employer issued check #1388 to claimant in the amount of $699.71. This check was not able to be cashed due to not sufficient funds. On September 17, 2012, employer issued a check in the amount of $699.70. Claimant has not been able to receive funds for this check. On September 27, 2012, claimant did receive $800.00 from employer. Wages are found due to claimant in the amount of $2,915.00. $ 315.00 wages earned 7/15/12-7/31/12 +$3,400.00 wages earned 8/1/12-9/30/12 $3,715.00 total wages earned $ 800.00 wages paid $2,915.00 DUE

STATE OF MICHIGAN RICK SNYDER

GOVERNOR

DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS

MICHIGAN OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION
MARTHA B. YODER
DIRECTOR

STEVE ARWOOD
DIRECTOR

March 1, 2013

Life in Lansing LLC 5700 Aurelius, Ste. 300 Lansing, MI 48911 Dear Re: vs. Life in Lansing LLC,

This letter is to advise you of the findings in the above referenced case. The investigation has disclosed that $2,915.00 is due to for wages earned during the period from July 15, 2012 to September 30, 2012. The attached sheet provides a detailed explanation on how this figure was obtained and calculated. If you agree with the findings, please submit a check or money order for $2,915.00 payable to office as soon as possible, but no later than March 15, 2013. to this

If you disagree with the findings and do not submit payment, a departmental determination order will be issued. When the order is issued, you will receive a copy of that order in the mail which will contain instructions on how to file an appeal. The order will be mailed to both parties, finding the money due and assess penalties in accordance with Section 18 of 1978 PA 390, the Payment of Wages and Fringe Benefits Act, as amended, MCLA 408.471 et seq. Both parties have 14 days from the date of the determination order to file an appeal. If voluntary payment is not made and an order is issued, penalties assessed include: x a 10 percent per annum interest penalty calculated on a daily basis in the amount of $0.79 per day beginning November 7, 2012; x a civil penalty of half of the amount found due not to exceed $1,000.00 in the amount of $1,000.00; and x a civil penalty in the amount of $300 for failing to provide the requested records during the investigation. A copy of Act 390 and administrative rules may be obtained at www.michigan.gov/wagehour or you may contact the divisions main office at (517) 322-1825 to request a copy be mailed. You may contact me at (517) 636-6261 if you have any questions or concerns. Sincerely,

Kristine Reigler, Investigator cc: Life in Lansing LLC P.O. Box 21055 Lansing, MI 48909
LARA is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available, upon request, to individuals with disabilities. WAGE & HOUR DIVISION P.O. BOX 30476 x LANSING, MICHIGAN 48909-7976 www.michigan.gov/wagehour x (517) 322-1825 x FAX (517) 322-6352

V. LIFE IN LANSING LLC INVESTIGATIVE FINDINGS On October 26, 2012, claimant filed a wage complaint alleging hourly wages due in the amount of $315.00 earned during the period of July 15, 2012 through July 31, 2012; salary due in the amount of $2,600.00 earned during the period of August 1, 2012 through September 30, 2012. The employer was notified of the allegations of the complaint by letter dated November 7, 2012. On January 16, 2013, a Notice to Produce Records was sent to the employer. To date, the employer has failed to respond to the allegations of this complaint. Claimant was employed by this employer as Video Editor/Videographer from July 15, 2012 through September 30, 2012. Claimant was paid an hourly wage of $10.00 through July 31, 2012. During the period of July 15, 2012 through July 31, 2012, worked 31.5 hours, earning wages in the amount of $315.00 (31.5 hrs. x $10/hr.). Beginning August 1, 2012, claimants wage agreement changed to a semi-monthly salary of $850.00. Claimant worked four complete pay periods during the period of August 1, 2012 through September 30, 2012 (8/1/12-8/15/12; 8/16/12-8/31/12; 9/1/12-9/15/12; 9/16/12-9/30/12), earning wages in the amount of $3,400. On August 15, 2012, employer issued check #1354 to claimant in the amount of $283.00. This check was not able to be cashed due not sufficient funds. On September 3, 2012, employer issued check #1388 to claimant in the amount of $699.71. This check was not able to be cashed due to not sufficient funds. On September 17, 2012, employer issued a check in the amount of $699.70. Claimant has not been able to receive funds for this check. On September 27, 2012, claimant did receive $800.00 from employer. Wages are found due to claimant in the amount of $2,915.00. $ 315.00 wages earned 7/15/12-7/31/12 +$3,400.00 wages earned 8/1/12-9/30/12 $3,715.00 total wages earned $ 800.00 wages paid $2,915.00 DUE

Mailing Address: P.O. Box 30476 Lansing, MI 48909-7976 Telephone: 517.322.1825 Facsimile: 517.322.6352

MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS MICHIGAN OCCUPATIONAL SAFETY & HEALTH ADMINISTRATION WAGE & HOUR DIVISION

Street Address: 7150 Harris Drive Dimondale, MI 48821

NOTICE TO PRODUCE RECORDS

AUTHORITY: Act 390, Public Acts of 1978, As Amended COMPLETION: Mandatory PENALTY: Misdemeanor
LARA is an equal opportunity employer/program. Auxiliary aids, services, and other reasonable accommodations are available, upon request, to individuals with disabilities. Call 517.322.1825 to make your needs known to this agency.

Claim Number: 171217 Claimant Name: Business Name: Life in Lansing LLC Legal Identity: Life in Lansing LLC, Attention: Address: 5700 Aurelius Rd., #300 Lansing, MI 48911 On November 7, 2012 notification of the above-referenced complaint was mailed requesting a statement of any disagreement with the claim and submission of copies of time records, payroll records including gross earnings & itemization of deductions, written agreements or written policies, commission statements, canceled checks, or other information necessary to resolve the claim. The requested records were not provided. Section 9 of the Payment of Wages and Fringe Benefits Act, 1978 PA 390, MCL 408.471 et seq., requires an employer to maintain a record for each employee to include the employee's name, birth date, occupation or classification in which employed, total basic rate of pay, total hours worked each pay period, total wages paid each pay period and a separate itemization of deductions and to make these records available for inspection by the department. The department also has authority pursuant to Section 11(5), to require the production of any records or documents it considers relevant or material to an investigation. NOTICE It is therefore directed that copies of the following records be submitted to this office no later than January 30, 2012: daily time records, payroll records, canceled checks, written agreements and any other information used to determine your payroll for from July 15, 2012 to September 30, 2012. FAILURE TO PROVIDE THE REQUESTED RECORDS CONSTITUTES A VIOLATION OF THE PAYMENT OF WAGES AND FRINGE BENEFITS ACT AND MAY RESULT IN A CIVIL PENALTY OF $300.00. Any records or information you submit will be considered in the department's decision. Absent a response, the investigation will be concluded and a determination issued based upon evidence received by the department. The determination may include an order requiring payment of wages, fringe benefits, an interest penalty, exemplary damages of not more than twice the amount found due, a civil penalty not to exceed $1,000.00 and up to a $1,000.00 penalty for failing to provide records to the department during the investigation. Department Representative Kristine Reigler Investigator / (517) 636-6261 Date 1/16/13 Cc: Life in Lansing LLC, P.O. Box 21055 Lansing, MI 48909

Limited Liability Company Details

Michigan.gov Home

LARA Home | Sitemap | Contact | Online Services | Agencies

Searched for: LIFE IN LANSING LLC ID Num: E0037M Name:LIFE IN LANSING LLC Type: Domestic Limited Liability Company Resident Agent: MARCUS FRANCOEUR Registered Office Address: 5700 AURELIUS RD #300 Mailing/Office Address: Formation/Qualification Date: 11- 19- 2007 Jurisdiction of Origin: MICHIGAN Managed by: Members Status: ACTIVE Date: Present LANSING MI 48911

View Document Images

Return to Search

New Search

Michigan.gov Home | LARA Home | LARA Contact | State Web Sites Privacy Policy | Link Policy | Accessibility Policy | Security Policy Copyright 2001- 2013 State of Michigan

http://www.dleg.state.mi.us/bcs_corp/dt_llc.asp?id_nbr=E0037M&name_entity=LIFE%20IN%20LANSING%20LLC[1/15/2013 12:18:03 PM]

Wright, Kim (LARA)

From: Sent: To: Subject: Reigler, Kristine (LARA) Tuesday, December 18, 2012 8:14 AM Reigler, Kristine (LARA) v. Life in Lansing INVESTIGATION REPORT

Claimant called obtain status update . Investigator advised employer has not responded and requested claimant provide copies of pay stubs or any other information he has to help substantiate his claim. Kristine Reigler, Investigator Michigan Department of Licensing and Regulatory Affairs Michigan Occupational Safety and Health Administration Wage & Hour Division 7150 Harris Drive l PO Box 30476 l Lansing, MI 48909 Direct: (517) 636-6261 Fax: (517) 322-6352
Informationprovidedinthisresponsemaycontainlegalinformation.Legalinformationisnotthesameaslegaladvicetheapplicationoflawtoanindividual's specificcircumstances.Thedivisionwilldoitsbesttoprovideyouwithinformationthatisaccurateanduseful,butitisrecommendedyouconsultalawyerifyou wantprofessionalassurancetheinformation,andyourinterpretationofit,isappropriatetoyourparticularsituation.


Theinformationcontainedinthistransmissionisintendedonlyfortheuseoftheindividualorentitynamedabove,andmaycontaininformationthatisprivileged,confidential, andexemptfromdisclosureunderapplicablelaws.Ifyouarenottheintendedrecipient,youarenotifieddissemination,distribution,orduplicationisstrictlyprohibited.Ifyou havereceivedthismessageinerror,pleasedeleteitfromyoursystemandnotifythesender.

Wright, Kim (LARA)

From: Sent: To: Subject: Attachments: Thursday, November 08, 2012 12:41 PM Reigler, Kristine (LARA) Vs Life In Lansing - Correction needed in amount paid on document received today wage_complaint_form_7816202.pdf; Scan of letter receved Nov 8th with mistake of payment recieved.jpeg

Dear Kristine Reigler, Thank you for taking on my case. I received a letter today confirming this and something on it concerned me. Everything on the amount and wages section is correct except that they didn't pay me $80.00, they paid me $800.00. Just to make sure, I went back and looked at the original complaint form I submitted and it does say $800.00 . Was this just a misprint on the letter sent to me or was it also on the letter sent to life in lansing? I just really would like to avoid any confusion especially on the other end of things. I understand the offices are closed today and other cases need to come first, but if you could clarify this one aspect of the investigation I would be extremely grateful. I will include a copy of the original complaint form as well as a copy of the letter I received today with the correction highlighted. Thanks so much, I look forward to hearing from you.

CLAIM NUMBER:

EMPLOYMENT WAGE COMPLAINT

Michigan Department of Licensing and Regulatory Affairs Michigan Occupational Safety and Health Administration Wage & Hour Division Street Address: Mailing Address: 7150 Harris Drive P.O. Box 30476 Dimondale, MI 48821 Lansing, MI 48909-7976 Telephone: 517.322.1825 Facsimile: 517.322.6352 Website: www.michigan.gov/wagehour EMPLOYEE INFORMATION Please print
LAST NAME, FIRST NAME, MIDDLE INITIAL X Mr. ADDRESS (STREET NUMBER AND NAME): Ms. Mrs. Miss.

IMPORTANT: By filing this claim with the Wage and Hour Division, you are electing a remedy which may prevent you from pursuing this claim elsewhere, including civil court. LARA is an equal opportunity employer/program. Auxilliary aids, services and other reasonable accommodations are available, upon request, to individuals with disabilities for the purpose of accessibility under the state and federal law. Please call 517.322.1825 to make your needs known to this agency. AUTHORITY: ACT 390, PUBLIC ACTS OF 1978, AS AMENDED ACT 154, PUBLIC ACTS OF 1964, AS AMENDED COMPLETION: VOLUNTARY PENALTY: NONE

Dr.

LAST 4 NUMBERS OF SOCIAL SECURITY NUMBER: BIRTH DATE:

CITY, STATE, ZIP:

COUNTY:

EMAIL ADDRESS:

PRIMARY TELEPHONE NUMBER:

DAYTIME TELEPHONE NUMBER:

CONTACT INFORMATION FOR SOMEONE WHO WILL ALWAYS KNOW HOW TO REACH YOU.

ADDRESS WHERE YOU WORKED (STREET NUMBER AND NAME): CITY, STATE, ZIP:

5700 Aurelius Road, Suite 300

COUNTY:

Lansing MI 48911
Start date of employment (Month/Day/Year): Employment Status:

Ingham
07/15/2012
Last date worked (Month/Day/Year): How often were you paid?

09/30/2012
SEMI-MONTHLY MONTHLY

QUIT

DISCHARGED

STILL EMPLOYED PER HOUR

WEEKLY SALARY

BI-WEEKLY COMMISSION

LIST YOUR RATE OF PAY: PROVIDE A COPY OF YOUR CHECK STUB.

PIECE RATE/OTHER

$ 850.00

If salaried, how many days/hours were you required to work each week or pay period? 5d

What was/is your job title?

Video Editor/Videographer

EMPLOYER INFORMATION
BUSINESS NAME: TYPE OF BUSINESS:

Life In Lansing
BUSINESS ADDRESS (STREET NUMBER AND NAME):

711 Performing Arts, Sports,

5700 Aurelius Road, Suite 300

CITY, STATE, ZIP: COUNTY

Lansing, MI 48911
TELEPHONE NUMBER: FAX NUMBER:

Ingham
EMAIL OR WEBSITE ADDRESS OF EMPLOYER (IF KNOWN):

www.lifeinlansing.com
NAME OF PERSON IN CHARGE OF DAY-TO-DAY OPERATIONS: LIST THE APPROXIMATE NUMBER OF EMPLOYEES:

10-12 Was Your Employment Governed by One or More Employers? If so, list below the additional employer's name, address, city, state, zip code, and telephone number or attach an addiitional sheet listing the information.

THE CLAIM WILL BE RETURNED IF A CLAIM AMOUNT AND A CLAIM PERIOD ARE NOT PROVIDED. Filing this complaint does not guarantee payment or a finding in your favor. Please provide documentation to substantiate your claim, for example, pay stubs, time sheets, written policies and ect.

Your Reason for Filing this Claim WAGES Hourly Wages Salary Commissions
(Provide list of commissions)

Period Claimed
Month/Day/Year to Month/Day/Year

Calculate Amount Claimed (Attach additional sheets if necessary)

Pay Periods (before taxes): 07/15/2012-07/31/2012 -->$315.00 hours worked: 31.5 (This pay period was hourly) (all following pay periods were Salary (($850.00 every 2 weeks)) but still kept tract of hours) 08/01/2012-08/15/2012 -->$850.00 hours worked: 58.5

Amount Claimed

7/15/2012 08/01/2012 / / / / / /

07/31/2012 09/30/2012 / / / / / /

315.00 2600.00

Piece Rate/Other Unauthorized Deductions FRINGE BENEFITS

(Provide written policy or contract)

Vacation Pay Paid Time Off Holiday Pay Sick Pay Expense Reimbursement
(Provide list of expenses)

/ / / / / / / / / / / / / / / /

/ / / / / / / / / / / / / / / /

08/16/2012-08/31/2012 -->$850.00 hours worked:97.5 09/01/2012-09/15/2012 -->$850.00 hours worked: 71.5 09/16/2012-09/30/2012-->$850.00 hours worked: 88 ____________________________________ _ TOTAL AMOUNT (before taxes) = $3715.00 total hours worked: 347 ____________________________________ _ was paid $800.00 on 9/27/2012 $3715.00 -$800.00 = $2,915.00 Amount owed before taxes

Bonus
(List type of bonus)

MINIMUM WAGE OVERTIME

2915.00

TOTAL GROSS (before tax deductions) AMOUNT CLAIMED Are you filing a complaint for pay stubs or wage statements you did not receive? If yes, please list dates you did not receive a pay stub or wage statement 08/16/2012-08/31/2012 - no pay stub 09/01/2012-09/15/2012 - no pay stub PLEASE ANSWER THE FOLLOWING YES Have you filed a law suit against the employer on the issues of this claim? If claiming fringe benefits, was a written policy or contract in effect during your employment? If yes, please provide a copy of the written policy or contract. Does the business make more than $500,000/year or transport goods outside of Michigan? Was your employment covered by a union contract? If yes, please submit a copy of the contract.
I certify that to the best of my knowledge and belief, this is a true statement of wages and/or fringe benefits due me. I will CERTIFICATION: inform the department if any of the following occur: Change of name, address, and/or telephone number for myself and/or employer, or a direct payment or settlement of the claim.

YES X

NO

NO X X X X

Signature of Complainant:

DATE: