Free D-22 Form - Nevada

NOTICE TO EMPLOYEES
Pursuant to: NRS 616B.227 Election by employee to report his tips; effect; regulation. 1. For the purpose of workers' compensation, an employee may elect to report the amount he receives as tips for the purpose of the calculation of compensation by submitting to his employer an Employee's Declaration of Election of Report Tips (form D-23). The employee must make his election separately for each pay period before the end of the next pay period. The declaration may not be amended. 2. Upon receipt of such notice the employer shall: (a) Make a copy of each report which the employee has filed with the employer to report the amount of his tips to the United States Internal Revenue Service or Employee's Declaration of Election to Report Tips; (b) Submit the copy to its workers' compensation insurer upon request, or if the employer is self-insured or an association of self-insured public or private employers, retain the copy for his records; and (c) If he is not self-insured, pay the insurer the premiums for the reported tips at the same rate as he pays on regular wages. 3. An employee who elects to report his tips is not eligible to receive increased compensation based on those tips until 3 months after his employer receives the Employee's Declaration of Election to Report Tips. For the purpose of workers' compensation, tips may be reported pursuant to 26 U.S.C. §6053(a) or on form D-23. The form for reporting tips D-23 can be obtained from your personnel office. If the forms are not available, contact your employer or the Internal Revenue Service.

D-22

(rev. 7/99)