Mandatory Notice and Acknowledgement
of Wage Rate and Designated Payday
per California Labor Law Section 2810.5
„„ California Labor Code Section 2810.5 requires that ALL NON-EXEMPT EMPLOYEES be
given written notice of their rate of pay and payday at time of hire or in the event of a
change in rate of pay or payday.
„„ Any non-exempt employee working under a Collective Bargaining Agreement (CBA)
does not need to be given a written notice if the CBA provides for wages, hours of
work, working conditions, and overtime pay.
„„ The regular rate of pay under the CBA must be at least 30% more than the CA State
minimum wage.
„„ This notice must be provided for each project for which freelance employees, crew,
and other project by project workers are hired.
„„ Workers must be paid the agreed rate for work in the hired category for that project.
„„ If their job changes, the rate of pay can change, but a new Notice must be provided.
Name ___________________________________________________
Work Start Date: ________________________
Email: ___________________________________________________
Job/Occupation Category: ___________________________________
Project Name (Job) Number: _________________________________
Work Site Employer / Production Co: ___________________________
DBA (if any): ______________________ FEIN:___________________
Street Address: ___________________________________________
City / ST/ Zip: ______________________________________________
Mailing Address: __________________________________________
City / ST/ Zip: ______________________________________________
Payroll Company: The TEAM Companies, Inc. „ 901 W. Alameda Ave., Ste 100, Burbank , CA 91506 „ Tel: 818.558.3261
Workers’ Compensation Insurance Carrier: CHARTIS CLAIMS, INC. „ P.O. Box 25977, Shawnee Mission, KS 66225 „ 800.736.6671
Regular rate of pay: $ ______________ per  hour
Overtime rate of pay: $____________ per  hour
 day (8 hours)  Other (explain): __________________________________
 other (explain): __________________________________________
(Overtime rate must be at least 1 ½ times the worker’s regular rate, to be paid after 8 regular hours per day.)
Allowances Taken:  None  Tips________ per hour,  Meals ____________ per meal  Lodging ____________  Other ________________
Regular Payday ____________________________  Weekly  Bi-Weekly  Other (if more frequent): _______________________________________
Notice Given:  At time of hire  Within 7 days of any change to the above information that is not shown on employee wage statement.
Unless exempt, the employee identified on this notice is entitled to minimum requirements for paid sick leave under state law which provides that an employee:
a. May accrue paid sick leave and may request and use up to 3 days or 24 hours of accrued paid sick leave per year;
b. May not be terminated or retaliated against for using or requesting the use of accrued paid sick leave; and
c. Has the right to file a complaint against an employer who retaliates or discriminates against an employee for
1. requesting or using accrued sick days;
2. attempting to exercise the right to use accrued paid sick days;
3. filing a complaint or alleging a violation of Article 1.5 section 245 et seq. of the California Labor Code;
4. cooperating in an investigation or prosecution of an alleged violation of this Article or opposing any policy or practice or act that is prohibited by Article 1.5
section 245 et seq. of the California Labor Code.
The following applies to the employee identified on this notice: (Check one box)
1. Accrues paid sick leave pursuant to the requirements of CA Labor Code §245.
2. Accrues paid sick leave pursuant to the employer’s policy which satisfies or exceeds the requirements of CA Labor Code §246.
3. Employer provides no less than 24 hours (or 3 days) of paid sick leave at the beginning of each 12-month period
4. Is exempt from paid sick leave under CA Labor Code §245.5. because: _________________________________________________________________
Employee Acknowledgement of Receipt
Employee’s signature below constitutes acknowledgement of receipt of this form.
Employee Signature _________________________________________________________________
Date __________________________
Date _________________________
 Check if employee declines to sign form.
Employer’s Representative’s Signature
Print Name of Employer’s Representative
Representative’s Phone
Representative’s Title
Representative’s Email
California Labor Code Section 2810.5(b) requires that the employer notify you in writing of any changes to the information set forth in this Notice within seven (7) calendar days after the time of the changes, unless one of the
following applies: (1) All changes are reflected on a timely wage statement furnished in accordance with Labor Code Section 226; or (2) Notice of all changes is provided in another writing within seven (7) days of the changes.
This form is an adaptation of the template issued by CA DLSE for compliance with CA Labor Code Section 2810.5. This form is not a contract.
Distribute copies of signed form as follows: One copy to Employee / One copy to payroll service / Employer/Production Company must retain the Original on file for 6 years.