1. Employee Information
Doing Business As (013A) Name(s):
2. Notice given:
Before a change in pay rate(s), allowances claimed or payday
3. Employee's rate of pay:
$ per hour
4. Allowances taken:
Tips per hour
Meals per meal
5. Regular payday:
6. Pay Is:
7. Overtime Pay Rate:
Most workers in NYS must receive at least 1½ times their regular rate of pay for all hours worked over 40 in a workweek, with few exceptions. A limited number of employees must only be paid overtime at 1½ times the minimum wage rate, or not at all.
This employee is exempt from overtime under the following exemption (optional):
8. Employee Acknowledgement:
On this day I have been notified of my pay rate, overtime rate told my (If eligible), allowances, and designated pay day on the date given below. I told my employer what my primary language is.
I have been given this pay notice In English because it is my primary language.My primary language is. I have been given this pay notice in English only, because the Department of Labor dose not yet offer a pay notice form in my primary language.
Print Employee Name
Preparer's Name and Title
Please note: It is unlawful for an employee to be paid less than an employee of the opposite sex for equal work. Employers also may not prohibit employees from discussing wages with their co-workers.