Notice of Pay Rate and Payday (Xincon) (HHA/PCA)

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law
Employer Information

Name: Xincon Home Health Care Services, Inc.

Doing Business As (DBA) Name(s):

FEIN (Optional): 26-1301111

Physical Address: 20 W 33rd Street, 6th Floor, Suite 2006A New York, NY 10001

Mailing Address: 20 W 33rd Street, 6th Floor, Suite 2006A New York, NY 10001

Phone: 212-560-9218
2. Select one type of supplement

401 retirement planBenefit CardNone
Check if the patient is from Aetna or VillageCare

Aetna or VillageCare
2. Notice given:

At hiringBefore a change in pay rate(s),
Employee's Rate choice for Aetna/Villagecare (Pick one location)

NYC 5 boroughsLI&Westchester
Employee's Rate choice (Pick one location):

NYC 5 boroughs：LI&Westchester
NYC 5 boroughs Rate for Aetna/Village

Maximum hourly wage: base salary $21.4 per hour + paid sick leave $0.74 per hour = $22.14Choose a welfare card: basic salary $19.6 per hour + welfare card $1.85 per hour + paid sick leave $0.69 per hour = $22.14Choose 401: base salary $19.6 per hour + 401 $1.85 per hour + paid sick leave $0.69 per hour = $22.14
LI&Westchester Rate for Aetna/Villagecare

Maximum hourly wage: base salary $20.55 per hour + paid sick leave $0.72 per hour = $21.27Choose a welfare card: basic salary $19.6 per hour + welfare card $0.98 per hour + paid sick leave $0.69 per hour = $21.27Choose 401: Basic salary $19.6 per hour + 401 $0.98 per hour + paid sick leave $0.69 per hour = $21.27
纽约市 5 个行政区房价：

Maximum hourly wage: base salary $21.4 per hour + paid sick leave $0.79 per hour = $22.19Choose a welfare card: basic salary $19.65 per hour + welfare card $1.79 per hour + paid sick leave $0.75 per hour = $22.19Choose 401: base salary $19.65 per hour + 401 $1.79 per hour + paid sick leave $0.75 per hour = $22.19Other
LI&Westchester Rate

Maximum hourly wage: base salary $20.55 per hour + paid sick leave $0.77 per hour = $21.32Choose a welfare card: basic salary $19.65 per hour + welfare card $0.92 per hour + paid sick leave $0.75 per hour = $21.32Choose 401: Basic salary $19.65 per hour + 401 $0.92 per hour + paid sick leave $0.75 per hour = $21.32Other
Employee's Rate
3a. Wage Parity Rates:
PTO blanks .
401A blank .
Benefit card blank .
4. Allowances takes: None

5. Regular payday:Friday

6.Pay is: Weekly
7. Overtime Pay Rate:
Per hour(This must be at least 1.5 times the workers regular rate with few exceptions.)
8. Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated pay day on the date given below. I told my employer what my primary language is.
Check one:

I have been given this pay notice in English only because it is my primary language.My primary language is (please enter below). I have been given this pay notice in English, because the Department of Labor does not yet offer a pay notice from my primary language.
Please enter your language here:
Print Employee Name
Employee Signature

Clear
Today's Date

MonthDayYear
Date
times the worker’s regular rate with few exceptions
Preparer’s Name and Title
The employee must receive a signed copy of this form. The employer must keep the original for 6 years.
Annotate Image
Should be Empty:

Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law

3a. Wage Parity Rates: