Fill and Sign the Dept of Labor Forms Nytha

New York State Department of Labor Division of Labor Standards Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law Pay Notice for Employees Paid a Weekly Rate or a Salary for a Fixed Number of Hours (40 or Fewer in a Week) Employer Company name: _______________________________________ FEIN (optional): ______________________________________ Street address: ________________________________________ City and state: ________________________________________ Zip code: ____________________________________________ Phone: ( _______ ) __________ - _________________________ Preparer’s name: ______________________________________ Preparer’s title: _______________________________________ Employee Name: _______________________________________________ Street address (include apartment): ________________________ _____________________________________________________ _____________________________________________________ City: ________________________________________________ State and zip code: _____________________________________ Phone: ( _______ ) ________ - ___________________________ Your rate of pay: ____________________________________________________________________________________________ Specify the number of hours (40 or fewer in a week) for which the weekly rate or the salary will be paid . Your overtime rate of pay: _____________________________________________________________________________________ Designated pay day: __________________________________________________________________________________________ Date Preparer’s signature General Statement Regarding Overtime Pay in New York State Most employees in New York State must be paid overtime wages of 1½ times their regular rate of pay for all hours worked over 40 hours per workweek. A very limited number of specific categories of employees must be paid overtime at a lower rate or not at all. I have been notified of my pay rate, overtime rate, and designated pay day on the date given below. Date Employee’s signature The employee must receive a duplicate signed copy of this form. The original must be kept by the employer. LS 56 (12/09)