Wage Statement
(Optional Form)
U.S. Department of Labor
Wage and Hour Division
Total Hours
Worked in
Week
Itemized Deductions
Crop/Task
Units Done
Total
Gross
Pay
Rate of Pay (Hour-
ly or Piece Rate)
Daily Pay
Other
Employer
Address
Employer identification number
Employee
Social Security No.
Permanent Address
Expires: 08/31/2020
OMB No.: 1235-0002
Workweek Ending
(Month, Day, Year)
Day/Date
Sun/
Mon/
Tues/
Wed/
Thurs/
Fri/
Sat/
Starting Time
Quitting Time
Hours Worked
FICA
Federal Tax
State Tax
Rent
Food
Transportation
Other
Total
Deductions
Net Pay
(Amount Due
Employed)
Date Paid:
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). 29 U.S.C. §§ 1821(d)-(e),(g), 1831(c)-(d),(f); 29 C.F.R. § 500.80. This form also satisfies statutory requirements under section 11 (c) of the Fair Labor Standards Act (FLSA).
29 U.S.C. § 211(c).
PAYROLL INFORMATION: Enter the month, day and year on which the MSPA worker's payroll workweek ends. Enter the calendar date of the day worked. Enter the time work started and ended
each day. Enter the total time actually worked each day. Subtract bona fide 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 daily pay computed at the hourly and/or piece rate.
ITEMIZED DEDUCTIONS: In addition to FICA (Social Security), federal tax, state tax, and rent, food, and transportation deductions (if any), enter any other specified deductions in right column
and then transfer to left column. Subtract total deductions from total Gross Pay. Enter the result as Net Pay (Amount Due Employee). Enter date worker is paid.
Persons are not required to respond to this collection of information unless it displays a currently valid OMB control number. This collection of information is authorized by MSPA sections 201(d)
and 301(c). 29 U.S.C. §§ 1821(d), 1831(c), 1851-1853; 29 C.F.R. § 500.80. While use of this form is optional, it is mandatory for MSPA-covered entities to maintain the information and to provide
it in written form. 29 U.S.C. §§ 1821(d),(e),(g), 1851, 1853, 1854; 29 C.F.R. § 500.80. The DOL uses this form to determine employer compliance with the MSPA.
PUBLIC BURDEN STATEMENT
We estimate it will take an average of one (1) minute to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. 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 of Labor, Wage and Hour 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 2011
