Free D-23 - Nevada

EMPLOYEE'S DECLARATION OF ELECTION TO REPORT TIPS
For the Purpose of Workers' Compensation Pursuant to NRS 616B.227

EMPLOYER: EMPLOYEE: EMPLOYEE IDENTIFICATION NUMBER: DEPARTMENT: SOCIAL SECURITY NUMBER: PAY PERIOD: TO

AMOUNT OF TIPS RECEIVED DURING PERIOD: $ I understand that the reporting of false information may disqualify me from receiving workers' compensation benefits, and may subject me to criminal and civil penalties. I declare under penalty of perjury that the information provided concerning the amount of tips which I have received is true and correct to the best of my knowledge. Those tips are declared as wages for the calculation of workers' compensation.

Employee Signature

Date

THIS FORM MUST BE SUBMITTED TO YOUR EMPLOYER BEFORE THE END OF THE PAY PERIOD THAT FOLLOWS THE PAY PERIOD INDICATED ABOVE.

D-23

(rev. 7/99)