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Fill and Sign the Employees Declaration of Election to Report Tips D 23 Form

Fill and Sign the Employees Declaration of Election to Report Tips D 23 Form

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EMPLOYEE'S DECLARATION OF ELECTION TO REPORT TIPSFor 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 SignatureDate THIS FORM MUST BE SUBMITTED TO YOUR EMPLOYER BEFORE THE END OF THE PAYPERIOD THAT FOLLOWS THE PAY PERIOD INDICATED ABOVE.D-23 (rev. 7/99)

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The best way to complete and sign your employees declaration of election to report tips d 23 form

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