Form Ls 57 - Notice And Acknowledgement Of Pay Rate And Payday
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1Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law
Notice for Employees Paid Salary for Varying Hours, Day Rate, Piece Rate, Flat Rate or Other Non-Hourly Pay
1. Employer Information
4. Employee’s Pay Rate:
8. Employee Acknowledgement:
$_____________ per _________
On this day, I received notice of my pay rate,
Name:
Specify the basis for the rate paid, i.e. salary for
overtime rate (if eligible), allowances, and
varying hours, day rate, etc.
designated payday. I told my employer what
Employers may not pay a non-hourly rate to a
my primary language is.
Doing Business As (DBA) Name(s):
non-exempt employee in the Hospitality
Check one:
Industry, except for commissioned salespeople.
I have been given this pay notice in English
5. Allowances taken:
because it is my primary language.
FEIN (optional):
None
Tips ________ per hour
My primary language is _____________.
Meals _______ per meal
Physical Address:
I have been given this pay notice in English
Lodging _______
only, because the Department of Labor does
Other __________________
not yet offer a pay notice form in my primary
language.
6. Pay is:
Mailing Address:
Weekly
Bi-weekly
Employee Signature
Other
Phone:
7. Overtime Pay Rate:
Date
In most cases the overtime rate will be 1½ times
the regular rate of pay for the week. The regular
rate of pay is the total weekly pay divided by
2. Notice given:
Preparer Name and Title
the hours worked in the week.
At hiring
The employee must receive a signed copy of
In most cases, it is illegal to pay a fixed weekly
this form. The employer must keep the original
rate for varying hours worked over 40 per week.
On or before February 1
for 6 years.
The Department of Labor strongly discourages
weekly rates for non-exempt employees, since
Before a change in pay rate(s),
underpayments often result.
allowances claimed or payday
3. Regular payday: ____________________
LS 57 (03/11)
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