Notice of pay rate and pay day (Wellcare) (PA)

Notice for Hourly Rate Employees
1. Employer Information

Name: Wellcare Health Management, Inc. as Fiscal Intermediary for
Mailing Address:
2. Notice given:

At hiringBefore a change in pay rate(s), Allowance claimed or payday
3. Empployee's rate of pay: per hour
4. Allowances takes:

None
5. Regular Payday:

Friday
6. Pay is:

Weekly
7. Overtime Pay Rate:
8. Emploee 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 because it is my primary languageMy primary language is (Please enter below) . I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary language.
Please enter your language:
Print Employee Name:
Employee Signature

Clear
Date

MonthDayYear
Date
Preparer’s Name and Title
The employee must receive a signed copy of this form. The employer must keep the original for 6 years.
Should be Empty:

Notice for Hourly Rate Employees