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

  • 1. Employer Information Name:
    Community Health Aide Services
    Doing Business As (DBA) Name(s):
    Community Home Care
    FEIN (optional):
    14-1694451
    Physical Address:
    49 North Airmont Rd,
    Montebello NY 10901
    Mailing Address:
    49 North Airmont Rd,
    Montebello NY 10901
    Phone:
    845-781-7376

  • 2. Notice given:
    ☒ At hiring
    ☐ Before a change in pay rate(s), allowances
    claimed or payday
    3. Allowances taken:
    ☒None
    ☐Tips______ per hour
    ☐ Meals ______ per meal
    ☐Lodging ________
    ☐Other

  • 4. Employee’s rate of pay:
    Your base pay is $16.20 per hour.


    Exceptions:
    If you work in New York City, your base pay will
    be $17 per hour.


    If you work in Long Island or Westchester, your
    base pay will be $17 per hour.


    Live in Rates:
    Live-in shifts will be paid the above-stated rates
    multiplied by 13 hours.

  • 5. Regular payday:
             Friday
    6. Pay is:
             Weekly
    7. Overtime Pay Rate:
    Overtime pay rate one-half the regular rate of pay for
    all hours worked more than 40/week. Your regular
    pay rate of pay is determined by dividing the total
    pay by the total hours you worked that week.

  • 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
    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 does not yet offer a pay notice
    form in my primary language.

       
    Print Employee Name
       
    Employee Signature
    Pick a Date   
    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.
    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.

  • Listed above is the minimum starting pay-rate per region. At the discretion of the case manager, pay-rates may increase/decrease on a case by case basis

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