Notice and Acknowledgement of Pay and Payday for Hourly ...
New York State Department of Labor Division of Labor Standards
Notice and Acknowledgement of Pay and Payday for Hourly Rate Employees
Employer Information Name:
Doing Business As (DBA) name(s):
FEIN: Physical Address:
Mailing Address:
Phone:
Notice given: At hiring On or before February 1 Before a change in pay rate(s), allowances claimed or payday.
LS 54 (3-11)
Employee's rate (s) of pay:
$___________ per ________ $___________ per ________ $___________ per ________
Allowances taken:
None Tips ________ per hour Meals _______ per meal Lodging _______ Other __________________
Regular payday: ____________________
Pay is: Weekly Bi-weekly Other
Overtime Pay Rate:
$______ per hour (This must be at least 1 ? times the workers' regular rate with few exceptions.)
Employee Acknowledgement: On this day, I received notice of my pay rate, overtime rate (if eligible), allowances and designated payday. I told my employer what my true primary language is. Check one: I accepted this pay notice in English, because it is my primary language. My primary language is ________. I accepted this pay notice in English because the Department of Labor does not yet offer a pay notice form in this language on its web site.
Print Employee Name
Employee Signature
Date
Preparer Name and Title The employee must receive a copy of this signed form. The employer must keep the original for 6 years.
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