Fill and Sign the Pay Rate 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 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 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)