Notice And Acknowledgement Of Pay Rate And Payday

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Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Employees Paid a Weekly Rate or a Salary for a Fixed Number of Hours (40 or Fewer in a Week)
1. Employer Information
3. Employee’s Pay Rate:
8. Employee Acknowledgement:
On this day, I have been notified of my pay rate,
overtime rate (if eligible), allowances, and
designated payday. I told my employer what
Weekly hours _______ (Specify the number of
my primary language is.
hours for which the weekly rate or salary will be
Doing Business As (DBA) Name(s):
Check one:
Employers may not pay a non-hourly rate to a
I have been given this pay notice in English
non-exempt employee in the Hospitality
because it is my primary language.
Industry, except for commissioned salespeople.
FEIN (optional):
My primary language is
. I
4. Allowances taken:
have been given this pay notice in English only,
Physical Address:
because the Department of Labor does not yet
per hour
offer a pay notice form in my primary language.
per meal
Mailing Address:
Print Employee Name
5. Regular payday:
Employee Signature
6. Pay is:
2. Notice given:
Preparer Name and Title
At hiring
On or before February 1
7. Overtime Pay Rate:
Before a change in pay rate(s),
per hour (This must be at least 1½
The employee must receive a signed copy of
allowances claimed or payday
times the worker’s regular rate, with few
this form. The employer must keep the original
for 6 years.
LS 56 (03/11)


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