HR Equal Pay Provision Form

HR EQUAL PAY PROVISION FORM

Employer Name:    Employer Address:

Personal Information

Position Information

Start Date:    Employment Type: Full-time Part-time Contractor

Equal Pay Provision — Statement and Required Documentation

Purpose: To document the factors supporting the employee's compensation and, where applicable, to document legitimate, job-related reasons for any pay differential between employees in substantially similar positions. This form is used to confirm compliance with applicable equal pay and anti-discrimination obligations and to record HR review and authorization.

Is there an identified pay differential between this employee and substantially similar peers?   Yes   No

Comparator Analysis — Comparator 1

Comparator Analysis — Comparator 2

Pay Differential Justification

Differential Amount (if any):    Date of Review:

Legitimate, job-related reasons claimed for any pay differential — check all that apply:

Seniority   Merit/Performance   Quantity/Quality of Production   Geographic Location   Education/Experience/Training   Shift Differentials/Unusual Hours   Other Bona Fide Factors (describe below)

Employment History

Most Recent Employer

From:    To:

Prior Employer

From:    To:

Education

References

Reference 1

Reference 2

Reference 3

Legal Disclosures and Authorizations

At-Will Employment: The employee acknowledges that, unless otherwise set forth in a separate written agreement signed by an authorized representative of the employer, employment is at-will and may be terminated by either party at any time, with or without cause or notice.

Employee acknowledges the At-Will Employment statement

Equal Opportunity: The employer affirms its commitment to equal employment opportunity and prohibits wage-setting decisions based on protected characteristics. All pay differentials must be supported by legitimate, job-related factors documented on this form.

Employee and reviewer acknowledge Equal Opportunity statement

Authorization: The employee authorizes the employer to contact prior employers and references for purposes of verification, and to conduct lawful background checks as required for employment or compensation review.

Employee authorizes contact of previous employers and relevant checks

HR Review & Compliance Determination

HR Review Completed: Yes   No

Determination: Compliant   Non-Compliant

HR Review Date:

Applicant / Employee Certification

I certify that all information provided on this form is true, complete, and accurate to the best of my knowledge. I understand that misrepresentation or omission of material facts may result in disciplinary action, up to and including termination. I acknowledge that compensation decisions documented herein have been reviewed and that I may request further explanation of the basis for any differential.

Employee Initials:

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