EMPLOYMENT SERVICES WORK FIRST MONTHLY TIME SHEET Due By The 5th work day of the Following Month

Name / SS#: ______Employment Worker / DIST #: ______

November 2014

SUNDAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY
ACTIVITY / 1
ACTIVITY / 2 / 3 / 4 / 5 / 6 / 7 / 8
ACTIVITY / 9 / 10 / 11 / 12 / 13 / 14 / 15
EMPLOYER NAME / 16 / 17 / 18 / 19 / 20 / 21 / 22
LENGTH OF LUNCH BREAK / 23 / 24 / 25 / 26 / 27 / 28 / 29
ARE YOU PAID FOR LUNCH BREAK? / 30
SUNDAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY
ACTIVITY / 1
ACTIVITY / 2 / 3 / 4 / 5 / 6 / 7 / 8
ACTIVITY / 9 / 10 / 11 / 12 / 13 / 14 / 15
EMPLOYER NAME / 16 / 17 / 18 / 19 / 20 / 21 / 22
LENGTH OF LUNCH BREAK / 23 / 24 / 25 / 26 / 27 / 28 / 29
ARE YOU PAID FOR LUNCH BREAK? / 30

Component or Employer Signature: ______

Component or Employer Signature: ______

Customer Signature: ______Telephone Number: ______

November 2014

SUNDAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY
ACTIVITY / 1
ACTIVITY / 2 / 3 / 4 / 5 / 6 / 7 / 8
ACTIVITY / 9 / 10 / 11 / 12 / 13 / 14 / 15
EMPLOYER NAME / 16 / 17 / 18 / 19 / 20 / 21 / 22
LENGTH OF LUNCH BREAK / 23 / 24 / 25 / 26 / 27 / 28 / 29
ARE YOU PAID FOR LUNCH BREAK? / 30
SUNDAY / MONDAY / TUESDAY / WEDNESDAY / THURSDAY / FRIDAY / SATURDAY
ACTIVITY / 1
ACTIVITY / 2 / 3 / 4 / 5 / 6 / 7 / 8
ACTIVITY / 9 / 10 / 11 / 12 / 13 / 14 / 15
EMPLOYER NAME / 16 / 17 / 18 / 19 / 20 / 21 / 22
LENGTH OF LUNCH BREAK / 23 / 24 / 25 / 26 / 27 / 28 / 29
ARE YOU PAID FOR LUNCH BREAK? / 30

Component or Employer Signature: ______

Component or Employer Signature: ______

Customer Signature: ______Telephone Number: ______

(11/08)