SampleCaliforniaMealandRestPeriodAttestationForm
_____________________________ ___________________________
Date StoreNo.
AssetforthintheCompany’sTimekeepingPolicyCaliforniaOnly,theCompanyprovidesme
witha30minutemealperiodbeforeIhaveworkedmorethan5hoursinaworkday(absenta
validwaiver).OnworkdayswhenIworkmorethan10hours,theCompanyprovidesmewitha
secondmealperiodbeforeIhaveworkedmorethan10hours(absentavalidwaiver).Iamalso
authorizedandpermittedtotakepaidrestperiodsasoutlinedintheTimekeepingPolicy
CaliforniaOnly.
IunderstandthatiftheCompanydoesnotprovidemewitharequiredmealperiodorauthorize
andpermitmetotakearequiredrestperiod,Imustreportthisonthe“MealandRestPeriod
ExceptionReport”sectionofthisform,below.IfurtherunderstandthatIcannotcombinemyrest
breaks(s)withmymealperiod(s)orusemyrestbreaksand/ormealperiodstomodifymy
regularworkschedule.
Bymysignaturebelow,underpenaltyofperjury,IcertifythatIwasauthorizedandpermittedto
takealloftherestperiodsandwasprovidedwithallofthemealperiodstowhichIwasentitled
inaccordancewiththeTimekeepingPolicyCaliforniaOnly.IunderstandthattheCompanyis
relyingontheinformationIhaveprovidedthroughthisformtocomplywithCaliforniaand
FederalWageandHourlaws.
Falsificationofanemployee’stimerecordisaseriousoffenseandwillsubjecttheoffending
employeetodisciplineuptoandincludingtermination.