Form Ls 59 - Notice And Acknowledgement Of Pay Rate And Payday
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1Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Exempt Employees
3. Employee’s pay rate(s): State if pay is
8. Employee Acknowledgement:
1. Employer Information
based on an hourly, salary, day rate,
On this day, I received notice of my pay
piece rate, or other basis.
rate, overtime rate (if eligible), allowances,
Name:
and designated payday. I told my employer
what my primary language is.
Employers may not pay a non-hourly rate to
Check one:
a non-exempt employee in the Hospitality
Doing Business As (DBA) Name(s):
Industry, except for commissioned
I have been given this pay notice in
salespeople.
English because it is my primary language.
My primary language is
. I
4. Allowances taken:
FEIN (optional):
have been given this pay notice in English
None
only, because the Department of Labor
Tips
per hour
does not yet offer a pay notice form in my
Physical Address:
Meals
per meal
primary language.
Lodging
Other
Print Employee Name
5. Regular payday:
Mailing Address:
Employee Signature
6. Pay is:
Weekly
Bi-weekly
Date
Phone:
Other:
7. Overtime Pay Rate:
Preparer Name and Title
Most workers in NYS must receive at least
2. Notice given:
1½ times their regular rate of pay for all
The employee must receive a signed
hours worked over 40 in a workweek, with
copy of this form. The employer must
At hiring
few exceptions. A limited number of
keep the original for 6 years.
Before a change in pay rate(s),
employees must only be paid overtime at
allowances claimed, or payday
1½ times the minimum wage rate, or not at
Please note: It is unlawful for an employee
all.
to be paid less than an employee of the
opposite sex for equal work. Employers also
This employee is exempt from overtime
may not prohibit employees from discussing
under the following exemption (optional):
wages with their co-workers.
LS 59 (01/17)
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Parent category: Business