Arizona State Personnel System
OVERTIME COMPENSATION ELECTION FORM
(FLSA Non-Exempt Employees Only)
Name (Print) EIN
Official Job Title
Agency/Division/Section
Initial Election
Cancel Prior Election and Begin New Election
I understand that as an employee entitled to overtime compensation under the Fair Labor Standards Act (FLSA), for
each hour that I work in excess of 40 hours per work week, I may elect to receive additional pay at one and one-half
times my regular rate of pay or I may elect to receive compensatory leave at a rate of one and one-half hours for
each excess hour worked or I may elect either. However, I realize that the agency reserves the right to pay cash
even though I may elect to receive compensatory leave for overtime worked. Please select one of the following
options:
I elect to receive only compensatory leave at a rate of one and one-half hours for each hour worked in excess
of 40 hours per work week.
I elect to accept either compensatory leave at a rate of one and one-half hours or cash payment at a rate of
one and one-half times my regular rate of pay for each hour worked in excess of 40 hours per work week. I
realize that my ability to receive cash payment is subject to the agency authorizing it and having funds
available to pay cash for overtime. I understand that I will typically receive compensatory leave as payment for
excess hours worked. However, I further understand that if special circumstances exist, I may receive cash
payment for excess hours worked.
I elect to accept only cash payment at a rate of one and one-half times my regular rate of pay for each hour
worked in excess of 40 hours per work week. I realize that this election will affect my ability to work overtime if
and when the agency does not have funds available to pay cash for overtime.
This election is not the result of any force or coercion by the agency. It will remain in effect until it is cancelled by me
and new
election is made or until I am no longer entitled to overtime compensation under the Fair Labor
Standards Act (FLSA). I understand that if I cancel this election and a new election is made, the new election will
be effective on the first day of the pay period following receipt of the new election by my agency.
Effective Date
Signature Date
cc: Employee
Supervisor
Employee Personnel File
ASPS/HRD-FA4.02 08/1
6
FOR HR USE ONLY
