5200-16 Overtime Holiday Rate Reduction Form

OMB Number: 0583-XXXX
Expiration date:
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0583-XXXX. The time required to complete this information collection is
estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information
U. S. Department of Agriculture
Food Safety and Inspection Service

Overtime/Holiday Rate Reduction Form
Purpose: The purpose of this form is to collect information to determine whether an establishment inspected by the Food Safety and Inspection Service qualifies
for an overtime and holiday fee reduction.
Definitions: For the purposes of this form, terms are defined as follows:
Affiliated Companies: Companies are considered affiliated with each other when one controls the other, or a third-party controls both. It does not matter whether
control is exercised, so long as the power to control exists. Affiliated companies can be domestic or foreign. Affiliated companies do not typically include entities
that perform contracted services, including human resource support and cleaning services, as defined in 13 CFR §121.103.
Company: Any organization/entity (including an Establishment) that buys or sells good or services. A company may be organized in various forms, including
partnerships and corporations, and can be privately held or publicly traded.
Official Establishment: Any entity that slaughters or processes meat (including Siluriformes fish), poultry, or egg products at which inspection is required by the
Federal Meat Inspection Act, Poultry Products Inspection Act, or Egg Products Inspection Act. Establishments that function solely as Official Import Inspection
Establishments or exporting facilities are not eligible for fee reduction.
Employee: Employee means all individuals employed on a full-time, part-time, or other basis. The number of employees is the average number of employees,
calculated by summing the number of employees at the end of each pay period over the preceding 52 weeks and dividing by the total number of pay periods.
1. How many employees does your establishment have? (Choose One)
A.) Nine or fewer employees

C.) 500 or more employees

B.) Between 10 and 499 employees

Yes

2. Is your establishment affiliated with one or more companies? (If no, skip to #5)

No

3. If yes, how many total employees do the affiliated companies employ (not including your establishment) (Choose One)
A.) Nine or fewer employees

B.) Between 10 and 499 employees

C.) 500 or more employees

4. How many total employees does your establishment and all of its affiliates have (i.e., likely the sum of your responses to Q.1 and Q.3)
(Choose One)
A.) Nine or fewer employees

B.) Between 10 and 499 employees

C.) 500 or more employees

5. Does your establishment have average annual sales of: (Choose One)
A.) less than $2.5 million

B.) $2.5 million or more

6. Please provide below: Name, Title, Telephone Number, Email Address, and Work Address of Person Signing the Form
Name:

Title:

Telephone Number:

Email Address:

Work Address:

City:

State:

Employee
Signature:

Zip
Code:
Date:

7. Establishment Number and address of Establishment applying for overtime and holiday rate reduction
Establishment Name:
Establishment Address:

City:

State:

Zip
Code:

Persons making false, fictitious, or fraudulent statements or entries are subject to a $10,000.00 fine or imprisonment for not more than 5 years or both, as
prescribed by 18 U.S.C §1001.
FSIS 5200-16 (07/01/2021)