Prototype- Utah Attestation to the Employee Live-in Exemption

Utah Attestation to the Employee Live-in Exemption

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
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Utah Attestation to the Employee Live-in Exemption

For questions, please contact Morning Sun Financial Services at 1-844-450-5444
Employee Legal Name*

First NameLast Name
Employee Email*
example@example.com
Employer Legal Name*

First NameLast Name
Consumer Legal Name*

First NameLast Name
Employer Email*
example@example.com
Under the U.S. Department of Labor Fair Labor Standards Act (FLSA) - Home Care Rule revised regulations, I confirm that my employee listed below qualifies as a live-in domestic service worker and is exempt from the Fair Labor Standards Act overtime requirements. I attest to the following:

My worker resides on my premises either "permanently" or for "extended periods of time":
- "Permanently" - My worker resides on my premises permanently by living, working and sleepingon my premises seven days per week and therefore has NO home of his or her own; OR
- "Extended Periods of Time" - My worker resides on my premises for an extended period of time by living, working and sleeping on my premises for five days a week (120 hours or more) OR my worker spends less than 120 hours per week working and sleeping on my premises, but spends five consecutive days or nights residing on my premises.
My worker is/will be paid at least minimum wage for all hours worked. There is a written agreement signed by my worker and myself to determine the number of hours that my worker will work.
- Sleep time, meal time and other periods of time of complete freedom from work duties are excluded from work hours.
- If any of the designated freedom of time periods are interrupted, I must pay for that time worked.
- My worker may either leave the premises or stay on the premises during the designated freedom time periods.
- If there is ANY deviation to the written agreement, a new agreement must be made.
Signatures

I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law. Please see the Consumer Consent Disclosure at https://www.jotform.com/consumer-consent-disclosure/
By signing below, I acknowledge that I am the employer for this stated employee and that by declaring this exemption, I have complied with the requirements for this exemption and accept any and all legal responsibility including but not limited to any cost associated with litigation or fines that may result by falsely claiming this exemption. I understand that this attestation form does not constitute the written agreement between me and my worker.
I acknowledge that I have read and understand this document.
Employee Legal Name*

Legal First NameLegal Last Name
Employee Signature*

Clear
Date of Signature*

MonthDayYear
Date
Employer Legal Name*

Legal First NameLegal Last Name
Employer Signature*

Clear
Date of Signature*

MonthDayYear
Date
Please verify that you are human*
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Utah Attestation to the Employee Live-in Exemption

Utah Attestation to the Employee Live-in Exemption

Signatures