Steven Bellone Frank Nardelli
Suffolk County Executive Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
DOL-LW-4 1/15
REQUEST FOR GENERAL LIVING WAGE EXEMPTION
Living Wage Law, Suffolk County Code, Chapter 575 (2001)
BASIS FOR A GENERAL EXEMPTION
Exemptions may be granted by the Suffolk County Department of Labor, Licensing & Consumer Affairs
where application of the Living Wage Law to a particular form of compensation is found by the county to
violate specific state or federal statutory, regulatory or constitutional provision or provisions.
To be completed by Applicant/Employer/Contractor
NAME: ______________________________________________ DATE: _______________
REPRESENTATIVE: ____________________________________________
ADDRESS: ____________________________________________ TELEPHONE #: ________________
__________________________________________________________________________________________
AWARDING AGENCY: _____________________________________ CONTACT: ________________
TYPE OF CONTRACT: __________________________________________________________________
AMOUNT OF AWARD: _____________________ TERM OF CONTRACT: _______________________
1) TOTAL ESTIMATED ANNUAL BUDGET:
(a) WITH EXEMPTION: ____________________ (b) WITHOUT EXEMPTION: ________________
2) ANNUAL COST OF APPLICATION OF THE
LIVING WAGE LAW: [ 1 (b) - 1 (a) ] (c) ___________
3) PERCENTAGE INCREASE OF TOTAL ANNUAL BUDGET
IF THE APPLICATION FOR EXEMPTION IS DENIED: [ 2 (c) 1 (a) ] (d) ___________
4) NUMBER OF EMPLOYEES AFFECTED BY THE APPLICATION
OF THE LIVING WAGE REGULATIONS TO APPLICANT: (e) ___________
PARTICULARS OF EXEMPTION
The type of contract to which the Living Wage Law applies: ______________________________________
(Chapter 575-13 B1)
The specific or official name of the program: __________________________________________________
(Chapter 575-13 B2)
The statutory or regulatory authority for granting the contract*: _________________________________
(Chapter 575-13 B2)
The conflicting statutory, regulatory or constitutional provision(s) that makes compliance with the Living
Wage Law unlawful*: _____________________________________________________________________
(Chapter 575-13 B3)
*Enclose a copy of each provision and any factual explication & analysis of how compliance with Living Wage
Law would violate the cited provision(s) and the legal consequences that would attach if this violation were to
occur.
