Notice And Consent For Payroll Debit Card (New York State Employer) printable pdf download

Notice And Consent For Payroll Debit Card (New York State Employer)

Notice and Consent for Payroll Debit Card

Employer Information

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

Employee Work Location: __________________________ Phone Number: _______________________

Methods of Payment

As a New York State employer, we can pay your wages in cash or check. This does not require your

approval. We may also pay your wages by direct deposit or payroll debit card. These forms of payment

require you to approve. If you do not approve, we will pay you in cash or check.

If you would like to receive your wages by payroll debit card, please read and sign below.

Notification of Payroll Debit Card Rights

If you are paid by payroll debit card, you must be given:



Local access. There must be one or more automated teller machines (ATMs) that offer

withdrawal at no cost to the employee within a reasonable distance from your place of

employment or your employee’s home.



Access to payment in full. There must be a place where you can withdraw up to the total

amount of your wages for each pay period or the balance on your payroll debit card without a

fee.

Addresses of local ATMs that will provide free

Locations where you may withdraw up to the

withdrawals:

total amount of wages or balance on the card:

______________________________

Specified Address

Attached

______________________________

Website

You may not be charged fees for a payroll debit card by the employer or payroll card issuer for regular use of

the account. Prohibited fees include, but are not limited to: application fees, overdraft fees, maintenance fees,

and declined transactions fees at an ATM that does not provide free balance inquiries.

Payroll Debit Card Consent

On this day I have been notified of my options of payment methods. I give my consent to the above listed

employer to pay my wages through Payroll Debit Card. I have been informed of local ATM access with free

withdrawal.

________________________________________

______________________________________

Print Employee Name

Employee Signature

_______________________________

Date

LS 14 (1/17)

Notice And Consent For Payroll Debit Card (New York State Employer)