Fill and Sign the New York Acknowledgement 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 Multiple Hourly Rates 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: _______ per hour for _____________________ (type of work or shift) Your rate of pay: _______ per hour for _____________________ (type of work or shift) Your rate of pay: _______ per hour for _____________________ (type of work or shift) Your overtime rate of pay will be 1½ times the weighted average of your several rates of pay. The weighted average is the total regular pay for the week divided by the total hours worked in the week. Thus, your overtime rate may vary from week to week, depending on how many hours you worked at each 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 54 (12/09)