Fill and Sign the Exempt Employees Form

New York State Department of Labor Division of Labor Standards Notice and Acknowledgement of Pay Rate and Payda y Under Section 195.1 of the New York State Labor La w Pay Notice for Exempt Employees 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 whether the rate of pay is on an hourly, salary, day rate, piece rate or other basis. If pay is for a specified number of hours, state the number of hours. _________________________ You are exempt from a premium overtime pay rate under the _________________________ exemption. 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 54 (12/09)