Form 5200-16 Overtime Holiday Rate Reduction Form

OMB Number: 0583-0185

Expiration date: 01/31/2022

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 0583-0185. 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.

Please provide below: Name, Title, Telephone Number, E-mail Address, and Work Address of person signing the form:

Name:	Title:
Telephone Number:	Email Address:
Work Address:	City:	State:	Zip Code:
Employee Signature:			Date:

6. 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)