MSPA Wage Statement

Wage Statement                                                                                      U.S. Department of Labor
(Optional Form)                                                                                     Wage and Hour Division

Employee                                                                                      Social Security No.                                       OMB No.: 1235-0002          Expires: 01/31/2027
                                                                                                                                                        Workweek Ending
Permanent Address                                                                                                                                       (Month, Day, Year)
                                                                                                                                                          Total Hours
                                                                                                                                                          Worked in
Day/Date             Sun/             Mon/                Tues/             Wed/              Thurs/               Fri/                                      Week
                                                                                                                                       Sat/
Starting Time                                                                                                                                                                               Itemized Deductions
Quitting Time                                                                                                                                                             FICA
Hours Worked
                                                                                                                                                                          Federal Tax

                                                                                                                                                                          State Tax
Crop/Task
Units Done                                                                                                                                                                Rent

                                                                                                                                                                          Food
                                                                                                                                                             Total
                                                                                                                                                             Gross        Transportation
Rate of Pay (Hour-                                                                                                                                            Pay
ly or Piece Rate)                                                                                                                                                         Other

Daily Pay                                                                                                                                                                 Other
Employer
                                                                                                                                                                               Total
Address
                                                                                                                                                                             Deductions


                                                                                                                                                                               Net Pay       Date Paid:
                                                                                                                                                                             (Amount Due
Employer identification number                                                                                                                                                Employed)

                                                                                     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.

                                                                               PUBLIC BURDEN STATEMENT
 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.

 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