** Where input is necessary
*** If applicable
**** Use one or the other possibility given in between the asterisks
to: **Legal name and address of the employer**
re: **** **Name and address of employee** or The employees named on the attached list****
In accordance with subsection 251.1(1) of the Canada Labour Code, you are hereby ordered to pay, within 15 days from the date you received this payment order, to the Receiver General for Canada, on account of **** **name of employee** or the employees named on the attached list**** the total amount of $**amount**, less deductions permitted pursuant to paragraphs 254.1(2)(a), (b) and (e) of the Code.
****(Use this paragraph in the case of one employee)
This amount represents non-payment of the following amounts as required under ****section or sections**** **section(s) number(s)** of Part III of the Canada Labour Code:
**type / amount / period of unpaid wages**
(If more than one employee, use the following paragraph)
This amount represents non-payment of wages and other amounts, as indicated against each employee named on the attached list. (Note to Inspector: The attached list of employees should include the type / amount / period of unpaid wages for each employee).****
Payment in accordance with this payment order is made by certified cheque or money order, payable to the Receiver General for Canada, and delivered or mailed to the undersigned inspector. Payment must be accompanied by a statement identifying deductions which have been made pursuant to paragraphs 254.1(2)(a), (b) and (e) of the Code.
This payment order may be appealed to an independent referee, appointed by the Minister to hear the matter, by any of the parties affected by this order. The referee may confirm, rescind or vary, in whole or in part, the payment order and may award costs in the proceedings. Should you wish to appeal this payment order, you must do so, in writing, to the Minister of Labour, within 15 days after its service.
For an appeal by an employer to be heard, the appeal request must be accompanied by a certified cheque or money order, payable to the Receiver General for Canada, in the amount indicated in the payment order as well as a statement identifying deductions permitted by paragraphs 254.1(2)(a), (b) and (e) of the Code. This money will be held in trust, with interest, pending the resolution of the appeal. However, if your appeal request is received after the expiration of the 15-day appeal period, it is inadmissible and the monies received may be remitted to the ****employee or employees**** in satisfaction of this payment order. Your appeal request should be addressed to the Minister of Labour, c/o **proper title of the Labour Regional Head, name and address of the regional office**.
Failure to pay the amount due or to appeal this payment order as set out above, may result in this order being filed in Federal Court in accordance with subsection 251.15(1) of the Canada Labour Code.
Issued at **place**, this **day** day of **month**, **year**.
**Print name of inspector**, Inspector
**Complete address of inspector**
Telephone Number: **Telephone number**
Fax Number: **Fax number**
**** **Name of employee** or The employees named on the attached list****
Note to the Inspector:
Service of this payment order or a copy of it can be made either in person or by registered or certified mail. If by mail, the payment order is presumed to have been received by the addressee on the seventh day after the date of mailing unless there is information to the contrary. [ss.251.1(3), Canada Labour Code]