Notice For Hourly Rate Employees
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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 Hourly Rate Employees
1. Employer Information
3. Employee’s rate of pay:
8. Employee Acknowledgement:
$
per hour
On this day I have been notified of my pay rate,
Name:
overtime rate (if eligible), allowances, and
4. Allowances taken:
designated pay day on the date given below. I
None
told my employer what my primary language is.
Tips
per hour
Doing Business As (DBA) Name(s):
Check one:
Meals
per meal
I have been given this pay notice in English
Lodging
because it is my primary language.
Other
My primary language is
. I
FEIN (optional):
have been given this pay notice in English only,
5. Regular payday:
because the Department of Labor does not yet
offer a pay notice form in my primary language.
Physical Address:
6. Pay is:
Weekly
Print Employee Name
Bi-weekly
Mailing Address:
Other
Employee Signature
7. Overtime Pay Rate:
$
per hour (This must be at least 1½
times the worker’s regular rate with few
Date
Phone:
exceptions.)
Preparer’s Name and Title
2. Notice given:
At hiring
On or before February 1st
Before a change in pay rate(s),
The employee must receive a signed copy of
allowances claimed or payday
this form. The employer must keep the original
for 6 years.
LS 54 (03/11)
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