Fillable Printable Form WH-516

Form WH-516

Migrant and Seasonal Agricultural

Worker Protection Act

U.S. Department of Labor

Wage and Hour Division

OMB NO: 1235-0002

Expires: 08/31/2020

Worker Information—Terms and Conditions of Employment

1. Place of employment: ________________________________________________________________________________________________

2. Period of employment: From _______________________ To ___________________________

3. Wage rates to be paid: $ __________________ per Hour Piece Rate $____________________ per _______________________

4. Crops and kinds of activities: __________________________________________________________________________________________

5. Transportation or other benets, if any: __________________________________________________________________________________

________________________________________________________________________________________________________________

Charge(s) to workers, if any: __________________________________________________________________________________________

6. Workers’ compensation insurance provided: Yes ________ No _________

Name of compensation carrier: ________________________________________________________________________________________

Name and address of policyholder(s): ___________________________________________________________________________________

________________________________________________________________________________________________________________

Person(s) and phone number(s) of person(s) to be notied to le claim: _________________________________________________________

________________________________________________________________________________________________________________

Deadline for ling claim: ______________________________________________________________________________________________

7. Unemployment compensation insurance provided: Yes _________ No ___________

8. Other benets: __________________________________________________________________________ Charge(s) _________________

9. For migrant workers who will be housed, the kind of housing available and cost, if any: _____________________________________________

________________________________________________________________________________________________________________

Charge(s) _________________________________________________________________________________________________________

10. List any strike, work stoppage, slowdown, or interruption of operation by employees at the place where the workers will be employed. (If there

are no strikes, etc., enter “None”):

________________________________________________________________________________________________________________

11. List any arrangements that have been made with establishment owners or agents for the payment of a commission or other benets for sales

made to workers. (If there are no such arrangements, enter “None”):

________________________________________________________________________________________________________________

Name of Person(s) Providing This Information: ______________________________________________________________________________

Note: The Department of Labor–Wage and Hour Division makes this form available in certain other languages to enable employers to satisfy the

requirement that the terms and conditions of employment be disclosed in a language common to the workers. Contact the nearest office of the

Wage and Hour Division to obtain such forms.

While completion of Form WH516 is optional, it is mandatory for Farm Labor Contractors, Agricultural Employers, and Agricultural Associations

to disclose employment terms and conditions in writing to migrant and day-haul workers upon recruitment, and to seasonal workers other than

day-haul workers upon request when an offer of employment is made to respond to the information collection contained In 29 CFR §§ 500.75-

500.76. This optional form may be used to disclose the required information. Thereafter, any migrant or seasonal worker has the right to have, upon

request, a written statement provided to him or her by the employer, of the information described above. This optional form may also be used for

this purpose.

We estimate that it will take an average of 32 minutes to complete this collection of information, including the time to review instructions, search

existing data sources, gather and maintain the data needed, and complete and review the collection of information. If you have any comments

regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, send them to the

Administrator, Wage and Hour Division, Room S3502, 200 Constitution Avenue NW, Washington, D.C. 20210. Do NOT send the completed form

to this office.

Persons are not required to respond to this information unless it displays a currently valid OMB number.

Optional form WH516 ENG

REV 06/14