Written Notice And Acknowledgement Of Pay Rate And Designated Payday Form
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1New York Labor Code Section 195(1)
Rev. 2/3/2015
Written Notice and Acknowledgement of Pay Rate and Designated Payday
New York State Wage Theft Prevention Act requires that ALL employees be given written notice of their regular rate of pay, wage
status and payday at time of hire.
Production Co./Employer ________________________________________________________ FEIN (Optional) ___________________
Physical address _______________________________ City ____________ State ______ Zip ________ Phone (____) ____ - ________
Mailing address ________________________________ City ____________ State ______ Zip ________ Phone (____) ____ - ________
Payroll Company __________________________________________________
nd
th
Address _30 West 22
Street, 5
Floor_____________ City _New York____ State _NY__ Zip _10010 _ Phone (212) 366 - 9390
Employee Name ________________________________________________ E-mail Address __________________________________
Address___________________________________________________ City ___________________ State _______ Zip______________
Your Job/Occupation Category is _________________________________________ Hire Date _________________________________
Project Name (Job) / Number ___________________________________________________
Non-Exempt Employees: Regular rate(s) of pay $__________ per hour.
Weekly Overtime: Rate of pay $__________ per hour, for all hours over 40.
Daily Overtime (if applicable): After ______ hours $ ________ per hour, and after ______ hours $ ________ per hour.
If working under a CBA: Other terms and conditions per CBA ________________________________________________Agmt/Local.
------ OR ------
Exempt Employees: Rate(s) of pay $ ______________ (State if pay is based on a weekly salary, day rate, piece rate, or other basis.)
If working under a CBA: Other terms and conditions per CBA ________________________________________________Agmt/Local.
Rate by: o Hour o Day o Week o Other (provide specifics): _________________
Employment agreement is: o Oral o Written
Allowances Taken: o None o Meals _________________ per meal o Lodging _________________ o Other _________________
Designated Payday ____________________ o Weekly o Bi- Weekly o Other _______________ if more frequent.
st
Notice Given: o At Hiring o Before a change in pay rate(s), allowances claimed, or payday o Annual, prior to February 1
.
Employee Acknowledgement:
On this date, I received written notice of my pay rate, overtime rate (if eligible), allowances, and
designated payday. I told my employer what my primary language is.
Check one:
o I have been given this notice in English because it is my primary language.
o My primary language is ______________________ . I have been given this notice in English only, because the Department of Labor
does not yet offer a notice form in my primary language.
Employee Signature _____________________________________ Date: ___________
_______________________________________________________________________
Preparer’s Name and Title
This notice form is an adaptation of the template notice form issued by the NY DOL on April 9, 2011 which may be found at
This notice form is made available as an aid to be in
compliance with section 195(1) of the New York Labor Code. It is not intended as legal advice or as a substitute for review by legal
counsel.
A signed copy to be provided to the employee and payroll company. Original should be retained by the production co./employer for at
least 6 years.
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