Sample California Meal and Rest Period Attestation Form

[Pages:2]Sample California Meal and Rest Period Attestation Form

_____________________________ Date

___________________________ Store No.

As set forth in the Company's Timekeeping Policy California Only, the Company provides me with a 30minute meal period before I have worked more than 5 hours in a workday (absent a valid waiver). On workdays when I work more than 10 hours, the Company provides me with a second meal period before I have worked more than 10 hours (absent a valid waiver). I am also authorized and permitted to take paid rest periods as outlined in the Timekeeping Policy California Only.

I understand that if the Company does not provide me with a required meal period or authorize and permit me to take a required rest period, I must report this on the "Meal and Rest Period Exception Report" section of this form, below. I further understand that I cannot combine my rest breaks(s) with my meal period(s) or use my rest breaks and/or meal periods to modify my regular work schedule.

By my signature below, under penalty of perjury, I certify that I was authorized and permitted to take all of the rest periods and was provided with all of the meal periods to which I was entitled in accordance with the Timekeeping Policy California Only. I understand that the Company is relying on the information I have provided through this form to comply with California and Federal Wage and Hour laws.

Falsification of an employee's time record is a serious offense and will subject the offending employee to discipline up to and including termination.

Meal/Rest Period Reason Key

(Please write the letter that corresponds with the reason for not taking a meal or rest period in accordance with your employer's policy in the "Reason Meal or Rest Period Was Not Provided" box below. For example, write "B" in the box if your workload prevented you from taking a meal or rest period. If your reason does not fix within options A, B, or C, please provide a written explanation in the box below.)

A. My supervisor did not authorize me to take a meal or rest period. B. My workload prevented me from taking a meal or rest period. C. My meal or rest period was interrupted because I was called back to work. D. Other (please explain in Reason box below)

Name

Employee # Signature

Meal Period Not Provided

Rest Period Not Provided

Reason

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