statement of tips

Connecticut Department of Labor

Wage & Workplace Standards Division

Tip Statement

I hereby attest as a "Service Employee" (Section 31-62-E2(c), Mandatory order No. 8), that during pay period ending I have received gratuities amounting to at least $2.00 per day (part-time) or $10.00 per week (full-time) and I acknowledge receipt of the amount of gratuities to exceed 29.3% of the minimum wage per hour credited by my employer as part of the minimum fair wage.

Signed:

Date:

Connecticut Department of Labor

Wage & Workplace Standards Division

Tip Statement

I hereby attest as a "Service Employee" (Section 31-62-E2(c), Mandatory order No. 8), that during pay period ending I have received gratuities amounting to at least $2.00 per day (part-time) or $10.00 per week (full-time) and I acknowledge receipt of the amount of gratuities to exceed 29.3% of the minimum wage per hour credited by my employer as part of the minimum fair wage.

Signed:

Date:

Revised 10/03