Fill and Sign the Pay Rate 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 Hourly Rate 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: _______________ per hour. Your overtime rate of pay: ______________ per hour. 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)