ls54

Name

First NameLast Name

Doing Business As DBA Names

FEIN optional

Physical Address

Mailing Address

Phone

Format: (000) 000-0000.

2. Notice Given

3. Employee’s rate of pay

Per Hour

4 Allowances Taken
None
Tips
Type a labelper hour
Meals
Type a labelper meal
Lodging
Type a label
   Other      Type a label

5 Regular payday

6. Pay is

7. Overtime Pay Rate

per hour (This must be at least1½ times the worker’s regular rate with few exceptions.)

8. Employee Acknowledgement: On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated pay day on the date given below. I told my employer what my primary language is.

Your Primary Language (If it is not English)

Check One

Print Employee Name

First NameLast Name

Employee Signature

Date

Preparers Name and Title

TitleFirst NameLast Name

The employee must receive a signed copy of this form. The employer must
keep the original for 6 years.

Please note: It is unlawful for an employee to be paid less than an employee of the opposite sex for equal work. Employers also may not prohibit employees from discussing wages with their co-workers.

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