Print Form
MINIMU
UM WAGE
E RATE (M
MWR) DEF
FERRAL A
APPLICAT
TION
FOR
R NON-PR
ROFIT EM
MPLOYERS
S
DEFERRA
AL THAT REQUIRES OFFIC
CE OF WAGE STANDARDS
S (OWS) APPROVAL
This application fo
or the MWR de
eferral is only for NON-PRO
OFIT CORPOR
RATIONS with TWENTY-SIX (26) OR MOR
RE EMPLOYEE
ES
must be subm
mitted along wiith supporting
g documents to
t wagesla@la
acity.org or th
he OWS address below.
and m
INA
ACCURATE OR INCOMPLET
TE SUBMISSIO
ONS WILL BE
E RETURNED.
Los A
Angeles Municipal Code (LAM
MC) Section 187.03, the Los Angeles
A
Minimu
um Wage Ordinance, allows Employers tha
at are Non-Profits
with 2
26 or more Employees to qua
alify for the defe
erral rate sched
dule specified i n LAMC Sectio
on 187.02.C, a
after approval b
by the OWS.
The M
MWR deferral for a Non-Pro
ofit Corporatio
on does not ex
xempt an Emp
ployer from co
omplying with
h any and all fe
ederal, state, or
o
local la
aws and regulations, includ
ding any applic
cable higher ffederal or statte minimum w
wage requireme
ent.
It is the Emp
ployer’s responsibility to ensure that the Employer is in
n compliance with any such
h laws and reg
gulations.
SECTION I. EMPLOYER
E
IN
NFORMATION
1. C
Company Name
e: ___________
____________
____________
_____________
____________
__ Phone Number: ________
____________
2. C
Company Addre
ess: _________
____________
_____________
____________
________ Ema
ail Address: ___
____________
____________
3. Iss your business
s a Non-Profit Corporation
C
witth valid 501(c)((3) status? ☐ Y
Yes
☐ No (Your business is NO
OT ELIGIBLE FOR
R A DEFERRAL.))
SECTION II. 501(c)(3)
5
ENTIITY VERIFICAT
TION
4. Employer Identiffication Numbe
er: _____ - ___
_____________
_
5. A
ATTACH a copy
y of your 501(c
c)(3) letter from the IRS and proceed
p
to SEC
CTION III below
w.
SECTION
S
III. DEFERRAL ELIIGIBILITY CRIITERIA
CH
HECK OFF ONE BOX THAT BES
ST DESCRIBES YOUR DEFERR
RAL ELIGIBILIT
TY CRITERIA ON
N PART A AND
ATTACH
H SUPPORTING DOCUMENTS L
LISTED ON PAR
RT B.
PAR
RT A. ELIGIBILITY
Y CRITERIA
☐ 11. The Chief Exxecutive
O
Officer (or highe
est paid
e
employee) mak
kes less
th
han five times the hourly
w
wage of the low
west paid
e
employee; or
PART B. SUPPORT
TING DOCUMENT
TATION REQUIRED
A.
A STATE the hourly wage of
o CEO (or HIG
GHEST paid em
mployee) in the organization a
as
of last comp
$ ________
pleted pay periiod:
_
B. STATE the hourly wage of
o LOWEST pa id employee in
n the organization as of last
completed pay period:
$ ________
C.
C MULTIPLY
Y B by 5: $ ___
______
D. Based on answers
a
above, is A less than
n C? ☐ Yes, p
proceed to Que
estion E. ☐ N
No
E. Has A been
n less than C fo
or twelve (12) continuous m
months?
☐ Yes (Proovide copies off the most receent three (3) moonths of payrolll records.)
☐ No (Youur business is NOT
N
currently e
eligible for a de
eferral under th
his eligibility critteria.)
☐ 22. Entity is a Trransitional
-
E
Employer as de
efined in
S
Section 10.31.1
1(h) of the
L
Los Angeles
A
Administrative Code;
C
or
Provide you
ur Transitional Job Opportunitties Program (T
TJOP) Certifica
ation Number:
TJOP-____
___; and
-
Copy of the
e City of Los An
ngeles TJOP C
Certification app
proval letter fro
om the Bureau of Contract
Administrattion, Office of Contract
C
Comp liance, Central ized Certification Administrattion.
•
A child care
e provider for purposes
p
of the
e MWR deferral must be eithe
er:
☐ A licensed child care Facility.
F
Provide
e a copy of Chiild Care Facilityy license from the Community
y
☐ 33. Entity is a chhild care
p
provider; or
censing Divisio
on(CCLD) of the
e California De
epartment of So
ocial Services (CDSS); or
Care Lic
☐ A licensse-exempted chhild care organ ization under C
California law. T
The State provvides
informattion on license--exempt child ccare facilities a
at http://ccld.ca.gov/res/pdf/LiccenseExemptChildCare.pdf. Provide your sservice type (i.ee., Boy & Girl Scouts, Boys & G
Girl Club,
YMCA, etc.)
e :
☐ 44. Entity is fundded
p
primarily (51% percent or
g
greater) by City
y, County,
S
State, or Federal grants
o
or reimburseme
ents.
A.
A STATE the amount of gov
vernment grantts and/or reimb
bursement from
m the previous tax year:
$ ________
______
B. STATE the total revenue derived from th
he previous taxx year: $ _____
_________
C.
C i) DIVIDE A by B, ii) then MULTIPLY byy 100: _______
__%
D. Based on answers
a
above, is C equal to o
or greater than
n fifty-one perc
cent (51%)?
☐ Yes (Proovide a copy off the most receent Return of O
Organization Exxempt From Inccome Tax
Form 99
90 or Short Forrm Return of O
Organization Exxempt From Inccome Tax Form
m 990-EZ with
all sched
dules, forms, supporting
s
state
ements as requ
uired by and filed with the IRS
S.)
☐ No (Youur business is NOT
N
currently
y eligible for a deferral under this eligibility criteria.)
If you DID NOT check off ANY boxes in
n PART A, your business is NOT
T ELIGIBLE for DEFERRAL.
If you checked off
o ANY BOX in PART
P
A, ATTAC
CH supporting do
ocumentation, SIIGN, and SUBMIT DEFERRAL F
FORM.
I dec
clare under penalty
y of perjury underr the laws of the State
S
of California that: (1) I am auth
horized to bind th
he entity listed abo
ove; (2) the inform
mation provided on
n
this fform is true and correct to the best of my knowledge
e; and (3) the entitty qualifies for one
om the MWR on th
he basis indicated
d above. By signing
g
e year deferral fro
below
w, I further agree th
hat should the entity
y listed above ceas
se to qualify for deferral because of a change in salary sstructure, non-profitt status, the hiring o
of Employees, or
any o
other reason that may
m affect the deferral eligibility, the en
ntity will notify the OWS
O
of such chang
ge and comply with
h the applicable MW
WR schedule speciified in LAMC
Section 187.02.
____
______________
______________
_________
___
______________
________
____
______________
_____________
____
P
Print Name of Person Completing This
s Form
Title
Signa
ature
Form O
OWS/MW-1, 07/16
OFFICE OF WAG
GE STANDARDS: 11
149 S. BROADWAY
Y, STE 300, LOS AN
NGELES CA 90015
________
_____________
Date
844-W
WAGESLA (924-3752
2)