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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30minute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