Westchester, Nassau, Suffolk

Nassau / Suffolk / Westchester
Notice and Acknowledgement of Pay Rate and Payday Under Section 195.1 of the New York State Labor Law for Home Care Aides Wage Parity and Other Jobs
Consumer:
Consumer Name

First NameLast Name
Consumer ID (can be found on pay stub)
Consumer Address:
Address
Apt.
City
State Zip Code
Employee:
Employee Name

First NameLast Name
Employee ID (can be found on pay stub)
Employee Email
example@example.com
Date

MonthDayYear
Date
Employee - Signature

Clear
Employee Name 1

First NameLast Name
Date Signed

MonthDayYear
Date
Employee Signature 1

Clear
Type option 1Type option 2
Should be Empty:

Nassau / Suffolk / Westchester