Employees Declaration Of Election To Report Tips
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Employees Declaration Of Election To Report Tips Form. This is a Nevada form and can be use in Workers Comp.
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Tags: Employees Declaration Of Election To Report Tips, D-23, Nevada Workers Comp,
EMPLOYEE'S DECLARATION OF ELECTION TO REPORT TIPS
For the Purpose of Workers' Compensation
Pursuant to NRS 616B.227
EMPLOYER:
EMPLOYEE:
EMPLOYEE IDENTIFICATION NUMBER:
DEPARTMENT:
SOCIAL SECURITY NUMBER:
PAY PERIOD:
TO
AMOUNT OF TIPS RECEIVED DURING PERIOD: $
I understand that the reporting of false information may disqualify me from receiving workers’
compensation benefits, and may subject me to criminal and civil penalties. I declare under penalty of
perjury that the information provided concerning the amount of tips which I have received is true and
correct to the best of my knowledge. Those tips are declared as wages for the calculation of workers'
compensation.
Employee Signature
Date
THIS FORM MUST BE SUBMITTED TO YOUR EMPLOYER BEFORE THE END OF THE PAY
PERIOD THAT FOLLOWS THE PAY PERIOD INDICATED ABOVE.
D-23
(rev. 7/99)
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