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 Multiple Hourly Rate Employees
3. Employee’s rate(s) of pay for each type of
each rate of pay. The overtime rate may vary
1. Employer Information
work or shift:
from week to week.
$_________per hour for ____________
Name:
8. Employee Acknowledgement:
$_________per hour for ____________
On this day I have been notified of my pay rate,
overtime rate (if eligible), allowances, and
$_________per hour for ____________
designated payday on the date given below.
Doing Business As (DBA) name(s):
I told my employer what my primary language
4. Allowances taken:
is.
None
Check one:
FEIN (optional):
Tips __________ per hour
I have been given this pay notice in
Meals _________ per meal
English because it is my primary language.
Lodging _________
My primary language is ______________.
Physical Address:
Other __________________________
I have been given this pay notice in English
only, because the Department of Labor does
5. Regular payday: ____________________
not yet offer a pay notice form in my primary
language.
Mailing Address:
6. Pay is:
_______________________________________
Weekly
Print Employee’s Name
Bi-weekly
Other
Phone:
Employee’s Signature
7. Overtime Pay Rate(s) for each type of work
2. Notice given:
or shift:
At hiring
Date
This must be at least 1½ times the worker’s
On or before February 1
weighted average of the multiple rates of pay
Before a change in pay rate (s),
for the week, with few exceptions. The
Preparer’s Name and Title
allowances claimed or payday
weighted average is the total regular pay
divided by the total hours worked in the week.
The employee must receive a signed copy of
The overtime rate may vary from week to week
this form. The employer must keep the original
depending on how many hours you worked at
for 6 years.
LS 55 (4/12)
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