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U.S. Department of Labor Departamento de Trabajo de (Department of Labor)

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U.S. Department of Labor Departamento de Trabajo de EE UU
Wage and Hour Division Sección de Horas y Sueldos
OMB No. 1235-0002
Expires/Se caduca: 08/31/2020
HOUSING TERMS AND CONDITIONS TÉRMINOS Y CONDICIONES DE LA VIVIENDA
Important Notice to Migrant Agricultural Worker: The Aviso Importante Para Obreros Agrícolas Migratorios: La
Migrant and Seasonal Agricultural Worker Protection Ley Para la Protección de Obreros Migratorios y
Act requires the furnishing of the following information. Temporeros exige que se provea la información siguiente.
1. The housing is provided by 1. La vivienda la provee
Name
Address
Nombre
Dirección
City & state / Zip code Ciudad y estado / Código Postal
2. Individual(s) in charge
2. Persona(s) encargada(s)
Name
Nombre
Address
Dirección
City & state / Zip code Ciudad y estado / Código Postal
Phone Teléfono
3. Mailing address of housing facility
3.Dirección de correo de la vivienda
Address
Dirección
City & state / Zip code Ciudad y estado / Código Postal
Phone Teléfono
4. Conditions of occupancy 4. Condiciones de ocupación
Who may live in housing facility
Quién puede habitar la vivienda
Charges made for housing (if none, so state) Cargos hechos por proporcionar la vivienda (Si no los
hay, declárelo)
Meals provided (if none, so state) Comidas proporcionadas (si no las hay, declárelo)
Charges for utilities (if none, so state) Cargos por servicios( luz, agua, gas) (si no los hay,
declárelo)
Other charges. if any Otros cargos, si los hay
Other conditions of occupancy Otras condiciones de ocupación
WH-521
Rev. 06/2011
Important Notice to Farm Labor Contractor, Aviso Importante Para Contratistas de Trabajo
Agricultural Employer, or Agricultural Association: Agrícola, Empleadores Agrícolas o Asociaciones
Agrícolas:
This form may be used for the disclosure required by
Se puede utilizar este formulario para la declaración
section 201(c) of the act. It must be posted in a
exigida por la sección 201 (c) de la ley. Se tiene que
conspicuous place or presented to each worker in
exhibir en un lugar conspicuo o se le tiene que dar una
English, Spanish, or another language, as appropriate.
copia a cada obrero en inglés, español u otro idioma,
según la necesidad.
Public Burden Statement Declaración Pública de Responsabilidad
We estimate that it will take an average of 30 minutes
Se calcula que tomará un promedio de 30 minutos para
to complete this information collection, including time
rellenar la compilación de esta información, incluyendo el
for reviewing instructions, searching existing data
tiempo para repasar las instrucciones, para buscar las
sources, gathering and maintaining the data needed,
fuentes informativas existentes, para recolectar y mantener
and completing and reviewing the information
la información necesaria, y para rellenar y repasar la
collection. If you have any comments regarding these
compilación de la información. Si tiene algún comentario
estimates or any other aspect of this survey, including
sobre estos cálculos o sobre cualquier otro aspecto de
suggestions for reviewing this burden, send them to
esta encuesta, incluyendo sugerencias para repasar esta
the Administrator, Wage and Hour Division, U.S.
responsabilidad, envíelos al Administrator, Wage and Hour
Department of Labor, Room S-3502, 200 Constitution
Division, U.S. Department of Labor, Room S-3502, 200
Avenue, N.W., Washington, D.C. 20210.
Constitution Avenue, N.W., Washington, D.C. 20210.
Persons ar e not requ ired to res pond to th e
Se le a visa al que rellene este formulario que no
collection o f informa tion unless it displa ys a
responda a la compilación de e sta in formación a
currently valid OMB control number.
menos que se encuen tre y se exhiba un número
actualmente válido de control de OMB.
WH-521
Rev. 06/2011
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Completed 19 July 2020

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