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NOTICE OF HIRE - EMPLOYMENT STATUS
AND ACKNOWLEDGEMENT OF WAGE RATE(S)

Notice of Hire (check only one)
At Hire
Current Employee
Annual-Current Date

Month

Day

Year

Change in pay rate(s) or payday
Effective Date:

Month

Day

Year

SECTION 1
Employer
Company Name
DBA
Permanent Address
Address Line 2
City	State	Zip Code
Mailing Address: Same as Physical Address
Address Line 2
City	State	Zip Code
Phone

Employee
Employee Name
Physical Address
City	State	Zip Code
Mailing Address: Same as Physical Address
Address Line 2
City	State	Zip Code
Phone

SECTION 2
Pay Frequency and Payday
Pay Frequency (Weekly, bi-weekly, semi-monthly, monthly, etc.)	Designated Pay Day (Day of week when wages are payable/available)

SECTION 3

Allowances Claimed As Part of Wages: None, or:

Tips $ per hour
Meals $ per meal
Lodging $ per
Other $ per

SECTION 4

Tipped Employees

D.C. Official Code § 32-1003(f)

The minimum hourly wage required to be paid by any employer to an employee who receives gratuities ("tipped minimum wage"), provided that the employee actually receives gratuities in an amount at least equal to the difference between the hourly wage paid and the DC minimum wage shall be as follows:

July 1, 2005: $2.77	July 1, 2017: $3.33	July 1, 2018: $3.89	July 1, 2019: $4.45	July 1, 2020: $5.00	July 1, 2021: $5.05
July 1, 2022: $5.35	May 1, 2023: $6.00	July 1, 2023: $8.00

D.C. Official Code § 32-1003(g)

All gratuities received by the employee must be retained by the employee, except that this provision shall not be construed to prohibit the pooling of gratuities among employees who customarily receive gratuities. Tip Pool Policy: (Explain if applicable)

SECTION 5

Basis of Wage Payment

Minimum Wage (per hour):

July 1, 2016: $11.50	July 1, 2017: $12.50	July 1, 2018: $13.25	July 1, 2019: $14.00
July 1, 2020: $15.00	July 1, 2021: $15.20	July 1, 2022: $16.10	July 1, 2023: 17.00

Living Wage Living Wage Exempt Employer Determined Wage Rate

Pay Basis (hourly, shift, day, week, salary, piece, commission)

Hourly

Rate of Pay
per hour

Overtime Rate of Pay*
per hour

Overtime Pay Exemption for bona fide
Administrative
Executive
Professional

Multiple Rates or Basis (for each type of basis)

Rate of Pay: per Overtime Rate:

* No employer shall employ any employee for a workweek that is longer than 40 hours, unless the employee receives compensation for employment in excess of 40 hours at a rate not less than 1 ½ times the regular rate at which the employee is employed.

SECTION 6
Prevailing Wage Rate (if Applicable)
Prevailing Rate Jobs: Your rate of pay will be the posted rate for the classification(s) listed.
Classification 1:	Prevailing Rate:
Classification 2:	Prevailing Rate:
Classification 3:	Prevailing Rate:

SECTION 7

The Department of Employment Services (DOES), through the Office of Wage-Hour (OWH), is the agency charged with enforcement of the District’s wage and hour laws. For questions and additional information, contact OWH at (202) 671-1880 or owh.ask@dc.gov. OWH is located at 4058 Minnesota Avenue, NE, Suite 3600, Washington, DC 20019. OWH’s office hours are Monday-Thursday 8:30am-4:30pm and Friday 9:30am-4:30pm.

SECTION 8

Employee Acknowledgement: By signing below, I acknowledge that I have received the foregoing information regarding my pay and my Employer. I told my employer what my primary language is: (Check one)

English - I have been given this pay notice in English.

Other Language

I have been given this pay notice in English only, because OWH does not offer a pay notice form in my primary language.

Employee's Signature
(checking the checkbox above is equivalent to a handwritten signature)

Employer's Signature
(checking the checkbox above is equivalent to a handwritten signature)

DOES provides templates for several common types of pay agreements including dual language notices and acknowledgments in English and Spanish. If any another language is needed, please contact OWH at (202) 671-1880. Employers may create their own notices, use or adapt the notice provided by DOES, as long as the:

Required information appears in English and the employee’s primary language
Employee receives a copy
Employee signs an acknowledgment of receipt and identifies their primary language to the employer
Employer keeps a copy of the notice and acknowledgment form

The Instructional Guide of how to complete this notice is found below:

INSTRUCTIONAL GUIDE

Notice Given
Indicate the reason the form is being provided to the employee.

Section 1
Employer and Employee
Complete all fields.

Section 2
Pay Frequency and Pay Day
Indicate the frequency (e.g., weekly, bi-weekly, etc.) for when regularly scheduled wage payments will be paid and also indicate the specific payday.

Section 3
Allowances Claimed as Part of Wages
Indicate any allowances claimed as part of the minimum wage, including tips, meals, and/or lodging allowances.

Section 4
Tipped Employees
This section provides tipped employees the required notice under §32-1003(f).

Note: Employers should also provide the company's tip pool policy in this section or as an attachment.

Section 5
Basis of Wage Payment
Employer must specify rather the employee is paid minimum wage, living wage (or living wage exempt) or if the wage rate is an employer determined rate above minimum wage.

Specify the basis as hour, shift, day, week, salary, piece, and/or commission.

Provide the actual rate for each type of basis the employee will be paid.

Note: Employers must also provide employees with their overtime rate for each basis paid or given notice that they are exempt from overtime. (Specify the reason for the exemption is for bona fide Administrative, Executive or Professional)

Section 6
Employees Paid Based on Prevailing Rates or other Jobs.
Complete this section when the employee will be paid a prevailing wage rate such as those specified under the Davis Bacon Act or the Service Contract Act.

Employers must specify the classification(s) the employee will work and the related Wage Rate and any Fringe Benefit applicable. Also, explain any overtime rates that will be paid for the work performed over 40 hours in a work week under each prevailing rate.

Section 7
According to WTPAA, information about how to contact the designated enforcement agency for concerns about safety, wage and hour, or discrimination is to be on this notice.

Section 8
Employee Acknowledgement
The employee must acknowledge that he/she has disclosed his/her primary language by checking one of the two boxes and that the employee has received the form by signing and dating the form.

Note: Employees have a right to receive this notice in a language other than English but only for those languages for which the DOES Office of Wage-Hour has developed its own dual-language notice. Notices will be available from Office of Wage-Hour in English and Spanish. If you need the forms translated in other languages, please contact our office at 202-671-1880.

If an employee refuses to sign the notice, an employer should still give the notice to the employee and note the employee's refusal on its copy of the notice.