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Project Owner/Management Agent Return Form To: THIS SECTION TO BE COMPLETED BY EMPLOYER Employee Name: Job Title: Presently Employed: Yes Current Wages/Salary: □ hourly □ weekly Date First Employed □ bi-weekly (check one) □ semi-monthly per hour Shift Differential Rate: □ monthly □ yearly Last Day of Employment □ other Year-to-date earnings: from: // through: // Average of regular hours per week: Overtime Rate: No Average of overtime hours per week: per hour Commissions, bonuses, tips, other: □ hourly □ weekly □ bi-weekly Average of shift differential hours per week: (check one) □ semi-monthly □ monthly □ yearly □ other List any anticipated change in the employee s rate of pay within the next 12 months: Effective date: If the employee s work is seasonal or sporadic, please indicate the layoff period(s): Additional remarks: Employer s Signature Employer s Printed Name Date Employer Company Name and Address Phone Fax E-mail NOTE: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction..
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