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Receipt For Payment Of Lost Or Denied Wages Employment Benefits Or Other Compensation WH-58 - Official Federal Forms

Receipt For Payment Of Lost Or Denied Wages Employment Benefits Or Other Compensation Form. This is a national form and can be used in US Dept Of Labor .
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Receipt For Payment of Lost or Denied Wages , Employment Benefits, or Other Compensation As computed or approved by the Wage and Hour Division Wage and Hour .Division U.S. Department . of Labor Employment Standards Administration hereby acknowledge receipt of payment in full (Type or print name of employee) from for the period beginning with the workweek ending (Name and location of establishment) through the workweek of unpaid wages, employment benefits, or other compensation due me ending (as shown in the column twhe right) unifier the Act(s) indicated in the marked box(es): The Fair Labor Standards Act 1 The Employee Polygraph Protection Act 2 The Family and Medical Leave Act 3 The Walsh-Healey Public Contracts Act H2A The Service Contract Act The Davis-Bacon and Related Acts Gross amount $ Legal deductions $ The Contract Work Hours and Safety Standards Act Title III - Consumer Credit Protection Act u Other Net amount received $ 'NOTICE TO EMPLOYEE UNDER THE FAIR LABOR STANDARDS ACT = Your acceptance of back wages due under the Fair Labor Standards Act means that you have given up any right you may have to bring suit for such back wages under Section 16(b) of that Act. Section 16(b) provides that an employee. may bring suit on his/her own behalf for unpaid minimum wages and/or overtime compensation and an equal amount as liquidated damages, plus attorney's fees and court costs. Generally, a 2-year statute of limitations applies to the recovery of back wages. o Do-not sign this receipt unless you have actually received payment of the back wages due. 2 NOTICE TO EMPLOYEE UNDER THE EMPLOYEE POLYGRAPH PROTECTION ACT - Your acceptance of lost wages and benefits under the Employee Polygraph Protection Act means that you have given up any right you may have to bring suit for such lost wages and benefits, attorney's fees and court costs. Generally, a 3=year statute of limitations applies to the recovery of lost wages and benefits. Do not sign this receipt unless you have actually received payment of the amounts due. 3NOTICE TO EMPLOYEE UNDER THE FAMILY AND MEDICAL LEAVE ACT - Your acceptance of lost or denied wages, employment benefits, or other compensation due under the Family and Medical Leave Act means that you have given up any right you may have to bring suit for Such amounts.under Section 107(a) of that Act. Section 107(a) provides that an employee may bring suit on his/her own behalf for lost or denied wages, salary,. employment benefits or other compensation,. interest on the lost or denied amounts calculated at the prevailing rate, an additional amount as liquidated damages, plus attorney's fees and court costs. Generally, a 2-year statute of limitations applies to the recovery of amounts due. Do not sign this receipt unless you have actually received payment of the amounts due. Signature of employee Date Address (Number, Street, (Apt. No.), City, State, ZIP Code) EMPLOYER'S CERTIFICATION To Wage and Hour Division , Employment Standards Administration, U.S. Department of Labor I hereby certify that I have on this (date) in full covering lost or denied wages , employment benefits, or other compensation as stated above. Signed (Employer or authorized representative) Title paid the above-named employee PENALTIES INCLUDING FINES OR IMPRISONMENT ARE PRESCRIBED FOR A FALSE STATEMENT OR MISREPRESENTATION UNDER U .S. CODE, TITLE 1 13, SEC. 1001. Form WH-58 (Rev. June 1998) American LegalNet, Inc. www.FormsWorkflow.com 1. WAGE AND HOUR COPY
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