Steven Bellone Frank Nardelli
Suffolk County Executive Commissioner
SUFFOLK COUNTY DEPARTMENT OF LABOR, LICENSING & CONSUMER AFFAIRS
DOL-LW-5 2/15
REQUEST FOR SPECIFIC LIVING WAGE EXEMPTION
Living Wage Law, Suffolk County Code, Chapter 575 (2001)
To be completed by Applicant/Employer/Contractor
Name:______________________________________________ Date:____________________
Representative:____________________________________________
Address:____________________________________________ Telephone #:_____________________
_________________________________________________________________________________________
Awarding Agency:__________________________________ Contact:______________________________
Amount of Award:_____________________ Term of Contract:______________________
BASIS FOR SPECIFIC EXEMPTION
1) YOUTH - Must submit proof on separate sheet of the following:
Recipient is an organization that regularly employs individuals under the age of 21 in a summer
youth or school-to-work program. Exemption applies only to such employees. (Chapter 575-13 A2) ________
2) SEASONAL EMPLOYMENT - Must submit proof on separate sheet of the following:
Recipient is an organization that employs seasonal employees. May be granted a permanent
exemption with respect to these employees with submission of proof that employees are
“seasonal” as defined in the Law. (Chapter 575-13 A4) ________
3) WAGE OR BUDGET EXEMPTION** - Must submit proof of the following:
a) Recipient provides proof that the highest paid employee of the corporation earns a salary which,
calculated on an hourly basis, is less than six times the lowest wage or salary paid by the corporation
(Chapter 575-13 A3a) ________
OR
b) Recipient demonstrates that fulfilling the requirements of the Living Wage Law will present a
hardship, directly increasing the expected total annual budget in an amount greater than 10% of the
prior year’s adopted budget. (Chapter 575-13 A3b) ________
c) For purposes of compensated time off, recipient demonstrates that any one of their part-time
employees fall into the wage level of 200% above the Living Wage ________
**NOTE: THE INFORMATION ON REVERSE SIDE MUST BE COMPLETED
FOR REQUESTS AS DESCRIBED IN 3 (a) OR 3 (b) ABOVE
