Minimum Wage Reporting Form - Office Of Human Rights - Montgomery County
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1Minimum Wage Reporting Form
Prototype 3-24-16
Please complete form, print the completed form and sign it, and then send it to the Office of Human Rights. The form
must be submitted within 30 days after the end of each quarter.
Business Information
Company Name
Address
City
State, ZIP
EIN
Contact Information
Name
Title
Phone
Email
Certification
Year / Quarter being reported
/
Number of Tipped workers
Payroll for Tipped Workers
"I certify that each tipped employee under my employment was paid the minimum wage during the
quarter being reported as required by Montgomery County Code, Chapter 27 - Human Rights and Civil
Liberties, Section 27-69 - Tipped Employees." The willful falsification of any of the above information may
subject employers to penalities and fines as outlined in the Montgomery County Code. Verification of
report data shall be at the discretion of the Montgomery County Office of Human Rights.
Signature
________________________________
Date
________________________________
Please mail completed form to:
Office of Human Rights
21 Maryland Ave, Suite 330
Rockville, MD 20850
Attention: Minimum Wage Reporting
Or e-mail scanned completed form to:
Wages@MontgomeryCountyMD.gov
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