Receipt for Payment of Lost or Denied Wages, Employment Benefits, or Other Compensation U.S. Department of Labor Employment Standards Administration Wage and Hour Division As computed or approved by the Wage and Hour Division I, , hereby acknowledge receipt of payment in full (typed or printed name of employee) from of unpaid wages, employment benefits, (name and location of the establishment) or other compensation due me for the period up to and including (as shown in the column to the right) under the Act(s) (end of investigation period) indicated in the marked box(es): |~J The Fair Labor Standards Act 1 [~"| The Service Contract Act [""[ The Employee Polygraph Protection Act 2 r~| The Davis-Bacon and Related Act | | The Family and Medical Leave Act 3 D The Contract Work Hours and Safety Standards Act | | The Walsh-Healey Public Contracts Act ~ | | ~ Title III - Consumer Credit Protection Act n Gross Amount $ Legal Deductions $ Net amount received $ H2A t-1 other 1 NOTICE TO EMPLOYEE UNDER THE FAIR LABOR STANDARDS ACT - Your acceptance of back wages due under the Fair Labor Standards Act means that you have given up any right you may have to bring suit for back wages under Section 16(b) of that Act. Section 16(b) provides that an employee may bring suit on his/her own behalf for unpaid minimum wages and/or overtime compensation and an equal amount as liquidated damages, plus attorneys' fees and court costs. The statute of limitations for Fair Labor Standards Act suits requires that a suit for unpaid minimum wages and/or overtime compensation must be filed within 2 years of a violation of the Act, except that a suit for a willful violation must be filed within 3 years of the violation. Do not sign this receipt unless you actually have received payment of all back wages due. 2 NOTICE TO EMPLOYEE UNDER THE EMPLOYEE POLYGRAPH PROTECTION ACT - Your acceptance of lost wages and benefits under the Employee Polygraph Protection Act means that you have given up any right you may have to bring suit for lost wages and benefits, attorneys' fees and court costs. Generally, a 3-year statute of limitations applies to the recovery of lost wages and benefits. Do not sign this receipt unless you have actually received payment of the amounts due. 3 NOTICE TO EMPLOYEE UNDER THE FAMILY AND MEDICAL LEAVE ACT - Your acceptance of lost or denied wages, employment benefits, or other compensation due under the Family and Medical Leave Act means that you have given up any right you may have to bring suit for amounts under Section 107(a) of the Act. Section 107(a) provides that an employee may bring suit on his/her own behalf for lost or denied wages, salary, employment benefits or other compensation, interest on the lost or denied amounts calculated at the prevailing rate, an additional amount as liquidated damages, plus attorneys' fees and court costs. The statute of limitations for Family and Medical Leave Act suits requires that a suit for amounts due must be filed within 2 years of a violation of the Act, except that a suit for a willful violation must be filed within 3 years of the violation. Do not sign this receipt unless you have actually received payment of the amounts due. Signature of employee Date Address EMPLOYER'S CERTIFICATION To Wage and Hour Division, Employment Standards Administration, U.S. Department of Labor I hereby certify that I have on this (Date) paid the above-named employee in full covering lost or denied wages, employment benefits, or other compensation as stated above. Signed Title (Employer or authorized representative) PENALTIES INCLUDING FINES OR IMPRISONMENT ARE PRESCRIBED FOR A FALSE STATEMENT OR MISREPRESENTATION UNDER U.S. CODE, TITLE 18, SEC. 1001. 1. WAGE AND HOUR COPY Form WH-58 (Rev. June 2006) American LegalNet, Inc. www.FormsWorkflow.com