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 Prevailing Rate and Other Jobs 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: ( ___ ) ___ - _____ Prevailing rate jobs : Your rate of pay will be the posted rate for the occupation. Your overtime rate(s), payable after 8 hours in a day and after 5 days in a week, or as noted in the applicable prevailing wage schedule, will be the posted overtime rate(s) for the occupation. Other Work : Your rate of pay: _________________________ per hour. Your overtime rate after working 40 hours in a week: _________________________ per hour. Mixed prevailing rate and other work in the same week : Your rate(s) of pay for each type of work will be as noted above. Your overtime rate(s) payable on prevailing rate jobs after 8 hours in a day and after 5 days in a week, or as noted in the applicable prevailing wage schedule, will be the posted overtime rate(s) for the occupation. Your overtime rate(s) payable after working 40 hours in a week will be 1½ times the straight time rate(s) of pay for the work you are doing after 40 hours in the week. Any overtime premium earned on the prevailing rate jobs during the week will be credited toward this overtime. 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)