• 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:
    845-425-6555

  • 2. Notice given:
    ☒ At hiring
    ☐ Before a change in pay rate(s), allowances
    claimed or payday

    Note: Live-in employees must be paid at least 13 hours for each 24 hour period, provided they receive 8 hours of sleep, with five hours of uninterrupted sleep and 3 hours off for meals. If an employee does not receive 5 hours of uninterrupted sleep, the employee must be paid for all 8 hours. If the employee does not receive meal periods free from duty, the employee must be paid for all 3 hours designated for meals.

  • 3. Employee’s Rate(s) of Pay for Each Type of Work Shift:
    $ see attached list per hour for __PA'S_____
    $______________ per hour for ______________
    $______________ per hour for ______________


    3a. Wage Parity Rates:
    $ see attached list per hour for regular wage
    $_____________ per hour for additional wage
    $_____________ per hour for supplemental wages*

  • 4. Allowances:
    ☒ None
    ☐ Tips______ per hour
    ☐ Meals ______ per meal
    ☐ Lodging ________
    ☐ Other

    5. Regular payday:________

    6. Pay is:
    ☒Weekly
    ☐Bi-weekly
    ☐Other:_________

  • 7. Overtime Pay Rate(s) for each type of work or shift:
    Single Pay Rate: $_______ per hour
    This must be at least 1½ times the worker’s regular rate with few exceptions.
    Wage Parity Pay Rate: $_______ per hour
    This must be at least 1½ times the worker’s regular rate with few exceptions.
    Multiple Pay Rates: $________ per hour
    This must be at least 1½ times the worker’s Weighted average of the multiple rates of pay for the week, with few exceptions.

  • 8. Employee Acknowledgement:
    On this date, I have been notified of my pay rate, overtime rate (if eligible), allowances, supplements and designated payday. 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
       

    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.

    *Attach Wage Parity supplement notification page 2.

  • LS 62 Notice to Wage Parity Home Care Aides - (cont’d)
    Benefit Portion of Minimum Rate of Home Care Aide Total Compensation

    *If wage supplements are paid as a single payment owed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement
    or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom
    payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

    List any additional benefits and attach listing to this document.

    Copies of the above listed agreements or summaries may be obtained by:
    __________Human Resources at 845-425-6555____________________

    Employee Acknowledgement:
    On this day I have been notified of my pay rate, overtime rate, allowances, supplements/benefits, and designated payday provided on this form (LS 62) attached and this addendum on the date given below.

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  • 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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