GSA5025
FLSA Exemption Determination Checklist - Administrative Exemption
GSA Form 5025 is the FLSA Exemption Determination Checklist for the Administrative Exemption, a two-page General Services Administration form, edition 11/2017. The PDF prints FLSA EXEMPTION DETERMINATION CHECKLIST with the subheading Administrative Exemption Checklist, and its footer reads GENERAL SERVICES ADMINISTRATION. GSA hosts it in its forms library.
The checklist has seven numbered questions about a position, with YES and NO boxes: a salary threshold, whether the primary duty is office or non-manual work related to management or general business operations, discretion and independent judgment on matters of significance, and a primary duty test. It cites 5 CFR 551.203, 551.104 and 551.206. The last question has EXEMPT and NON-EXEMPT boxes.
The form prints no name, signature or date line and no filing address. You can fill it out free in your browser on this page and download the result without an account.
Whether the annual rate of basic pay for the position is equal to or greater than $23,660. The form says basic pay includes locality payments and special rate supplements, but not premium payments, differentials or allowances. See 5 CFR 551.203.
Routing lines that send a YES answer on to the remaining questions and a NO answer to Question 7.
Whether the primary duty is office or non-manual work directly related to (a) management or (b) general business operations. Part a lists examples such as planning and controlling the budget. See 5 CFR 551.104 and 551.206.
Whether the primary duty involves discretion and independent judgment on matters of significance. The form lists 10 factors to consider, such as authority to commit the employer in matters that have significant financial impact.
Whether the employee spends more than 50% of work time on that work, or whether a duty under 50% may be credited under the three conditions the form lists.
EXEMPT and NON-EXEMPT boxes under the heading Administrative Exemption.
Check YES or NO for Question 1. The form says that if the answer is NO, go to Question 7.
Check YES or NO for Question 3a, management, and 3b, general business operations. The form says that if both are NO, go to Question 7.
Check YES or NO for both parts of Question 5, discretion and independent judgment, and matters of significance. The form sends a NO to Question 7.
Check YES or NO for Question 6 on the share of work time, or on the three conditions for crediting a duty under 50%.
In Question 7, the form says EXEMPT applies only if every answer was YES, and that a NO to any question means the employee is marked non-exempt.
These steps follow the routing printed on the form.
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
The form prints no filing address, routing or signature line.
5 CFR part 531, Subpart F; 5 CFR part 530, Subpart C; 5 CFR 551.203; and 5 CFR 551.104 and 551.206.
The footers print GSA 5025 11/2017 and GSA 5025 11/2017 BACK. GSA's page lists 11/2017 as the current revision date and leaves Authority or Regulation blank.
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The form does not say which office completes it. Its questions refer to an employee in this position and to the person answering as you.
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The form's footer reads GENERAL SERVICES ADMINISTRATION. GSA hosts it in its forms library.
Question 1 asks whether the annual rate of basic pay for the position is equal to or greater than $23,660. That figure is printed on the 11/2017 edition.
The form says that if you answered NO to any of the questions, the employee does not meet the definition for the administrative exemption and is marked as non-exempt.
5 CFR part 531, Subpart F, and 5 CFR part 530, Subpart C, for pay, then 5 CFR 551.203, 551.104 and 551.206.
No signature, name or date line is printed on either page.