GSA5026

FLSA Exemption Determination Checklist - Statutory Non-Exemption

Agency
GSA
Revision
Rev. 11/2017
Fillable fields
7
Pages
1
Official source
GSA form page
Checked
October 20, 2026
Fill GSA5026 online
Page 1 of form GSA5026

GSA Form 5026: FLSA Exemption Determination Checklist - Statutory Non-Exemption

GSA Form 5026 is the FLSA Exemption Determination Checklist for Statutory Non-Exemption, a one-page General Services Administration form, edition 11/2017. The PDF prints FLSA EXEMPTION DETERMINATION CHECKLIST with the subheading Statutory Non-Exemption Checklist, and its footer reads GENERAL SERVICES ADMINISTRATION. GSA hosts it in its forms library.

The checklist has five numbered questions with YES and NO boxes. They cover non-supervisory positions in the Federal Wage System or a comparable wage system, certain non-supervisory white-collar positions, the primary duty, and two exceptions: temporarily performing different work duties and the foreign exemption criteria. It cites 5 CFR 551.204 and 551.104. The last question has a single NON-EXEMPT box.

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.

Top of page 1 of GSA Form 5026: FLSA Exemption Determination Checklist - Statutory Non-Exemption, as printed by GSA

What's on GSA Form 5026

Question 1: Federal Wage System employees

Whether the employee is in a non-supervisory position in the Federal Wage System or in another comparable wage system. See 5 CFR 551.204.

Question 2: certain non-supervisory employees

Equipment operating and protective occupations and most clerical occupations; technician work positions properly classified below GS-9 (or equivalent), and many, but not all, above GS-9; and occupations requiring highly specialized technical skills and knowledge. See 5 CFR 551.204.

Question 3: primary duty

Whether employees in the Question 2 positions spend 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. See 5 CFR 551.104.

Question 4: exceptions

Whether an exception applies: (a) temporarily perform different work duties, or (b) fulfill the foreign exemption criteria.

Question 5: the result

A NON-EXEMPT box under the heading Statutory Non-Exemption. The form has no EXEMPT box.

How to complete GSA Form 5026

  1. 1

    Answer the wage system question

    Check YES or NO for Question 1 on non-supervisory Federal Wage System positions.

  2. 2

    Answer the position type question

    Check YES or NO for parts a, b and c of Question 2 on non-supervisory, white-collar positions.

  3. 3

    Answer the primary duty question

    Check YES or NO for Question 3 on the share of work time, or on the three conditions for crediting a duty under 50%.

  4. 4

    Answer the exceptions question

    Check YES or NO for Question 4a, temporarily performing different work duties, and 4b, the foreign exemption criteria.

  5. 5

    Mark the result

    The form says to mark these employees as non-exempt if you answered YES to Question 1 OR YES to Questions 2 and 3, and NO to Question 4.

These steps follow the order of the questions printed on the form.

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Routing, regulations and edition

Where it goes

The form prints no filing address, routing or signature line.

Regulations cited

5 CFR 551.204 for Questions 1 and 2, and 5 CFR 551.104 for the primary duty question.

Edition

The footer prints GSA 5026 11/2017. GSA's page lists 11/2017 as the current revision date and leaves Authority or Regulation blank.

Related forms

Who uses GSA Form 5026?

  • The person making the determination

    Question 5 says to mark these employees as non-exempt if you answered YES to Question 1 OR YES to Questions 2 and 3, and NO to Question 4.

  • Federal Wage System employees

    Question 1 is about an employee in a non-supervisory position in the Federal Wage System or in another comparable wage system.

  • Certain non-supervisory white-collar employees

    Question 2 is about employees in the non-supervisory, white-collar positions the form lists in parts a, b and c.

  • Not a public filing

    The checklist has no name, signature or date line, and prints no OMB number, Privacy Act notice or filing address. Its footer reads GENERAL SERVICES ADMINISTRATION.

The form does not say which office completes it. Its questions refer to the employee and to the person answering as you.

Official sources and the blank

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Questions about Form GSA5026

Who issues GSA Form 5026?

The form's footer reads GENERAL SERVICES ADMINISTRATION. GSA hosts it in its forms library.

Does GSA Form 5026 have an EXEMPT box?

No. Its only result box is NON-EXEMPT, under the heading Statutory Non-Exemption.

What exceptions does Question 4 list?

Two: whether the employees temporarily perform different work duties, and whether they fulfill the foreign exemption criteria.

Which regulations does GSA Form 5026 cite?

5 CFR 551.204 for the Federal Wage System and non-supervisory position questions, and 5 CFR 551.104 for the primary duty question.

Does GSA Form 5026 need a signature?

No signature, name or date line is printed on the form.