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Wage Statement WH-501 - Official Federal Forms

Wage Statement Form. This is a national form and can be used in US Dept Of Labor .
 Fillable pdf Last Modified 7/1/2008
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Wage Statement U.S. Department of Labor (Optional Form) Employment Standards Administration Wage and Hour Division Employee Social Security No. OMB No.: 1215-0148 Expires: 08-31-2006 Workweek Ending Permanent Address (Month, day, year) Total Hours Worked in Week Day/date Sun/ Mon/ Tues/ Wed/ Thurs/ Fri/ Sat/ Starting Time Itemized Deductions Quitting Time FICA Hours Worked Federal Tax Crop/Task State Tax Units Done Rent Food Total Gross Transportation Rate of Pay (Hour Pay ly or Piece Rate) Other Daily Pay Other Employer Total Address Deductions Net Pay Date Paid: (Amount Due Employer identification number Employed) Instructions Properly filled out, this optional form will satisfy the requirements of sections 201 (d), (e), and (g) and sections 301 (c), (d), and (f) of the Migrant and Seasonal Agricultural Worker Protection Act (MSPA). This forms also satisfies statutory requirements under section 11 (c) of the Fair Labor Standards Act (FLSA). If the employer chooses not to use this optional form, the information still must be maintained by the employer and provided to the employee in written form. PAYROLL INFORMATION: Enter the month, day and year on which the employee s payroll workweek ends. Enter the calendar date of the day worked. Ent er the time work started and ended each day. Enter the total time actually worked each day. Subtract bona f ide meal periods. Crop/Task - Units done - Enter the kind of work (such as picking oranges per bin) and the number of units produced if the employee is paid on a piece work or task basis. Enter the hourly or piece rate of pay. Enter the amount of the gross da ily pay computed at the hourly and/or piece rate ITEMIZED DEDUCTIONS: In addition to FICA (Social Security), federal ta x, state tax, and rent, food, and transportation deductions (if any), enter any other specified deductions in right column and then transfer to left. Subtract total deductions from total Gross Pa y - Enter the result as Net Pay (Amount Due Employee). Enter date work er is paid. NOTE: Persons are not required to respond to this collection of information un less it displays a currently valid OMB control number. BURDEN STATEMENT We estimate it will take an average of one (1) minute to complete this collection of information, including time for reviewing instructions, s earching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of informat ion. If you have any comments regarding these estimates or any other aspects of this information collection, including suggestions for reducing this burden, send them to the U.S. Department o f Labor, Employment Standards Administration, Administrator, Wage and Ho ur Division, Room S-3502, 200 Constitution Avenue, N.W., Washington, D.C. 20210. DO NOT SEND THE COMPLETED FORM TO THIS OFFICE Form WH-501 Rev. June 1998
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