SPECIAL SERVICE FOR GROUPS, INC.

Division Name: H.O.P.I.C.S CC 4360 Time Sheet for Employees

Employee Legal Name (print): Payroll Period:

McDowell Raven 02/1/22-02/15/22

Last Name, First Name (i.e. 01/01/02 – 01/15/02)
Non-Exempt (Hourly) Staff
Day Date *Code Lunch/Meal Period Regular OT Vacatio SL Other TOTA *CODES:
IN Out In OUT Hours Hours n
Hours Hours Hours L B Bereavement
D Disability
MON E Excused/Other,
Specify:
TUE 2/8 W/CA MEAL 4:30 PM 12: AM 7.5 1 8.5 * = COVID DIFF
*= CA MEAL PENT
WED 0 ___________________
THU 0 F FMLA
FRI 0 H
J
Holiday
Jury Duty
SAT 0 LWP Leave With
Pay
SUN 0 LWOP Leave
Without Pay
Subtotal Hours 8.5 S Suspension
SL Sick Leave
MON 2/14 W/CA MEAL 4:30 PM 12: AM 7.5 1 8.5 V Vacation
TUE 2/15 W/CA MEAL 4:30 PM 12: AM 7.5 1 8.5 W
WC
Work
Worker's
WED 0 Compensation

THU 0 If more than one (1) code

applies, under Code enter both.
FRI 0 Example: W/SL
SAT 0
SUN 0
Subtotal Hours 17
MON 0
TUE 0
WED 0
THU
FRI 0
SAT 0
MON 0
Subtotal Hours 0
SUMMARY OF ALL HOURS – MUST BE COMPLETED
Total Total Total Total Total
Regular OT Vacation SL Other
Hours Hours Hours Hours Hours

22.5 3 25.5
I attest under penalty of perjury that the information on this time record is a true and accurate record. I further attest that I have taken all the rest and meal periods to which I am
entitled in accordance with the provisions stated below.

I understand that I am entitled to a paid rest period of not less than ten minutes for every four hours of work, or major fraction thereof. I understand that the rest period must be
taken in the middle of each work period, insofar as is practical. I further understand that I may not waive the rest period or combine it with a meal period at any time.

I understand that I am entitled to a duty-free meal period of not less than 30 minutes when I work more than five hours.
I understand that the meal period must be taken before then end of the fifth (5th) hour.
I acknowledge that I have complied with these provisions.

Employee Signature: Date:

Supervisor/Director Signature: Date:

Rev. 3/20