Business Information
Employer Business Information
| Business Name |
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| Business Phone Number |
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| Business Mailing Address |
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| Business Location Address |
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| Total Number of Employees |
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| Business Type |
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| Total number of businesses you have within the County of Los Angeles |
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| Total number of businesses you have within the City of West Hollywood |
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Workforce Information
| Reason for Waiver Request |
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Supporting Documentation
Required Supporting Documentation - Declare Bankruptcy or Shutdown
| Submit a memo stating the business’ current financial status and how Ordinance No. 21-1168 for payment of a minimum wage will force the business to declare bankruptcy or be shutdown |
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| Submit a copy of the written notice sent to all Employees informing them of the business’ application for a waiver |
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| Submit the business’ State and Federal Tax Returns for the most recent three filed calendar years |
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| Submit business’ Profit and Loss (P&L) Statement for the last three calendar years |
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| Submit a projected financial statement for one year of projected income and finances with a written explanation as to how you expect to achieve this projection |
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| Submit business lease (if applicable) |
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Certification and Acknowledgement
Certification
| By submitting this application, I certify under penalty of perjury under the laws of the State of California that all information on this form and any additional supporting information submitted with this form is true and correct to the best of my knowledge. |
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| In submitting this waiver application, I understand that I must provide: (1) advance, written notice to all Employees of this application for waiver; and (2) written notice to all Employees of the City Manager’s or their designee's determination within three (3) business days after such determination is made. |
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| If I am approved for a waiver, I understand I will have to submit the business’ State and Federal filed tax returns for the year(s) in which the waiver is approved. |
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| If this waiver application is approved for a waiver due to the business’ reduction in workforce by more than 20% or the business’ reduction in Employees’ hours by more than 30%, I understand I will be required to submit IRS Form 941 on a quarterly basis during the waiver period. |
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| I understand this waiver is applicable to the payment of minimum wage only and will be subject to other provisions of West Hollywood Ordinance 21-1168. |
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| I further certify that I have read and understand West Hollywood Ordinance No. 21-1168 and will comply with this Ordinance as required by law. |
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Applicant Information
| Name of person completing this application |
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| Title of person completing this application |
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| Phone number of person completing this application |
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| Email of the person completing this application |
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