Instructions For San Francisco Paid Parental Leave Form - 2016 Page 2
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1
2
3
4Employer
Normal Gross Weekly Wage
Average Weekly Tips
1 GSA BAKERY
500
2 CON COFFEE
600
203
Option B. Fill out your information on your earnings from all employers over the past 3 months or 12
weeks based on your pay stubs or other records. Enter the date and pre-tax earnings for each pay period.
You should include the reported tips from each employer in the column titled “Tips” if you receive
reported tips at any of these jobs. Do not include pay periods where you were on unpaid or partially paid
leave. For example, if you were on pregnancy disability leave and were only receiving partial pay, do not
include those amounts.
Note that your employer may request proof of wages from other employers.
Below is an example of an employee who has one employer with that pays the same wages each for each
bi-weekly pay period and one employer with fluctuating wages where the employee also receives tips.
Employer 1: GSA BAKERY
Employer 2: CON COFFEE
Bi-Weekly
Weekly
Date
Wages
Tips
Date
Wages
Tips
Pay Period
Pay Period
1
31-Dec
500
1
24-Dec
644
220
2
14-Jan
2
31-Dec
620
167
3
28-Jan
3
7-Jan
611
201
4
11-Feb
4
14-Jan
510
241
5
25-Feb
5
21-Jan
687
181
6
11-Mar
6
28-Jan
495
191
7
7
4-Feb
616
141
8
8
11-Feb
645
232
9
9
18-Feb
479
187
10
10
25-Feb
630
209
11
11
4-Mar
610
237
12
12
11-Mar
653
229
Once you have completed the earnings grids, sign and date the form and return it to each employer.
[DEC 2016 REV]
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