Fill and Sign the Pay Notice for Employees Paid a Salary for Varying Hours Day Rate Piece Rate Flat Rate or Other Non Hourly Pay Form

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 Salary for Varying Hours, Day Rate, Piece Rate, Flat Rate or Other Non-Hourly Pay 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 pay is a salary for varying hours, day rate, piece rate, flat rate or another non-hourly basis ___________________________________________________________________________________________________________ Your overtime rate of pay will be 1½ times the total regular pay for the week divided by the total hours worked in the week. Designated pay day: __________________________________________________________________________________________ Note to Employers Regarding Weekly Pay Rates: Except in very limited circumstances, it is illegal to pay a fixed weekly rate for varying work weeks over 40 hours. The NYS Department of Labor strongly discourages weekly rates for non-exempt employees because of the frequent overtime violations which result. Even with a standard work week, there are usually occasions when work hours vary. The Department recommends that employers pay an hourly rate to non-exempt employees whose standard workweek is over 40 hours. 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 1 ½ 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 57 (12/09)