Written Notice And Acknowledgement Of Pay Rate And Designated Payday Form

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California Labor Code Section 2810.5
Rev. 05-02-2016
Written Notice and Acknowledgement of Pay Rate and Designated Payday
Effective January 1, 2012, the California Wage Theft Prevention Act of 2011, Labor Code section 2810.5(a) requires that ALL NON-
EXEMPT employees be given written notice of their regular rate of pay, wage status and designated payday at time of hire. Any non-
exempt employee working under a Collective Bargaining Agreement (CBA) does not need to be given a written notice if the CBA
underscores terms for wages, hours of work and working conditions of the employee as well as provides premium wage rates of all OT
hours worked and a regular rate of pay no less than 30% over the state minimum wage. For production employees, a written notice must
be provided for each project on which the employee is hired.
Production Co./Employer ____________________________________________________ FEIN (Optional) _______________________
Check all that apply:
Sole Proprietor
Limited Liability Company
General Partnership
Other name Employer is doing business as (if applicable): ________________________________________________________________
Physical address _______________________________ City ____________ State ______ Zip ________ Phone (____) ____ - ________
Mailing address ________________________________ City ____________ State ______ Zip ________ Phone (____) ____ - ________
Payroll Company __________________________________________________
Address ____________________________
500 S. Sepulveda Blvd., 4
Floor__________ City ___________
Los Angeles_ State _____
CA__ Zip ______
Phone (310) 440 - 9600
_____ ___ _____
Workers’ Compensation Insurance Carrier _______________________________________________
Arch Insurance Company (administered by Broadspire)__
Address _____________
P.O. Box 14352 _ _______________________ _ City ____ __
_______ State ____ _
KY Zip _ _____
_____ Phone (310) 440 - 9691
_____ ___ _____
Employee Name __________________________________________ E-mail Address ________________________________________
Address_______________________________________________________ City ___________________State _______Zip___________
Your Job/Occupation Category is _______________________________________
Hire Date __________________________________
Project Name (Job) / Number ___________________________________________________
Non-Exempt Employees: Regular rate(s) of pay $_______ per hour. Overtime rate(s): 1
x per hour ______. 2 x per hour _________
Additional regular rate(s) of pay per hour or premium overtime rate(s) (provide specifics): _______________________________________
Employment agreement is:
Allowances Taken:
Meals __ ______________ per meal
Lodging ________________
Other _________________
Designated Payday ____________________
Other _______________ if more frequent.
Notice Given:
At Hiring
Before a change in pay rate(s), allowances claimed, or payday.
Employee Acknowledgement of Receipt:
Employee Signature _________________________________________ Date: _________
Production Co. Signature _____________________________________ Date: _________
Labor Code section 2810.5(b) requires that the employer notify you in writing of any changes to the information set forth in this notice within
seven (7) calendar days after the time of the changes, unless one of the following applies: (a) All changes are reflected on a timely wage
statement furnished in accordance with Labor Code section 226; (b) Notice of all changes is provided in another writing required by law
within seven (7) days of the changes. The full text of Labor Code section 2810.5 may be found at Check
“Labor Code” and search for “2810.5” in quotes.
The employee’s signature on this notice merely constitutes acknowledgement of receipt. In accordance with an employer’s general
recordkeeping requirements under the law, it is the employer’s obligation to ensure that the employment and wage-related information
provided on this notice is accurate and complete. Furthermore, the employee’s signature acknowledging receipt of this notice does not
constitute a voluntary written agreement as required under the law between the employer and employee in order to credit any meals or
lodging against the minimum wage. Any such voluntary written agreement must be evidenced by a separate document.
This notice form is an adaptation of the template notice form issued by the CA DLSE on December 29, 2011 which may be found at
This notice form is made available as an aid to be in compliance with the CA Labor Code section 2810.5(a). It is
not intended as legal advice or as a substitute for review by legal counsel.
A signed copy to be provided to the employee and payroll company. Original should be retained by the production company/employer for
at least 3 years.


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