Division of Labor Standards - Letter of Representation - Employer Representative - Authorization and Information Form

Sep 15, 2026

Letter of Representation for Employer Representative under Division of Labor Standards, intended to be completed when representing an employer in a labor standards matter. The form collects employer/client details, the employer representative’s organization, title, contact information, and signature, and requires choices indicating role type. It also gathers additional legal and labor-context information (pending legal actions, correspondence, bankruptcy, collective bargaining agreements, and grievances). Includes a client authorization section allowing the representative to communicate and share necessary information, with dated pages and all required fields.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

1. Employer/Client Information

2. Employer Representative Information

3. Additional Information

4. Client(s) Authorization

Division of Labor Standards Letter of Representation – Employer Representative Fill in each item if you are representing an employer in a Labor Standards matter. Please see the Electronic Notice Option Form LS 33 to receive notices electronically. All fields must be completed. 1. Employer/Client Information Date: Case File Identification Number or Order to Comply Number: Employer/Business Name(s) : Subject of Claim (e.g. , minimum wage, overtime etc. ) : Complainant Name (if known) : 2. Employer Representative Information Organization/Firm Name: Name: Title: Choose One: Attorney Accountant Other: Signature: Address: Telephone: Fax: Email: LS 11.1 (03/23) Page 1 of 2 3. Additional Information (please complete all sections) Is your client involved in any pending legal actions regarding labor laws (lawsuits, etc. )? Yes No If yes, please provide details: Have any claimants or claimant representatives corresponded directly with you or your client regarding the subject of our investigation? Yes No If yes, please explain and provide copies of all correspondence along with this form. ___________________________________________________________________________ Is your client involved in a pending bankruptcy matter? Yes No If yes, please provide details including docket number, date, etc.: ___________________________________________________________________________ Is your client signatory to a collective bargaining agreement? Yes No If yes, please provide the union name and contact information, if available: ___________________________________________________________________________ If yes, are there any pending grievances related to labor law issues? Yes No If yes, please provide details: 4. Client(s) Authorization: I authorize the above named individual and/or organization to represent me in matters involving the case indicated above. You have my permission to communicate or share information with my representative as necessary. Client Name and Title: Client Signature: Client Name and Title: __________________________________________________________ Client Signature: LS 11.1 (03/23) Page 2 of 2

FAQs

What information must be completed in the employer/client section?

Fill in the date, case file identification/order to comply number, employer/business name(s), subject of claim, and complainant name (if known).

What additional legal and labor-related questions are included?

The form asks whether the client has pending legal actions, pending bankruptcy matters, is signatory to a collective bargaining agreement, and whether there are pending grievances related to labor law issues, including details if “Yes.”

What does the client authorization section allow the representative to do?

The client authorizes the named individual and/or organization to represent them and permits communication or sharing of information with the representative as necessary for the case.

Sep 15, 2026

Uploaded by Olivia Brown