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
1. Employer Information 3. Employee’s Rate(s) of Pay for Each 8. Employee Acknowledgement:
Type of Work Shift: On this date, I have been notified of
Name: CASTLE ROCK HC $ 20.34 per hour for ______________
my pay rate, overtime rate (if eligible),
allowances, supplements and designated
$ 0 per hour for ______________ payday. I told my employer what my
Doing Business As (DBA) Name(s): $ 0 per hour for ______________ primary language is.
3a. Wage Parity Rates:
$ 20.34 per hour for regular wage Check one:
FEIN (optional): $ .75 per hour for additional wage I have been given this pay notice in
$ 0 per hour for supplemental wages* English, because it is my primary
Physical Address: language.
4. Allowances:
2011WESTCHESTER AVE My primary language is .
None
I have been given this pay notice in
Tips per hour English only, because the Department of
Meals per meal Labor does not yet offer a pay notice form
Mailing Address: SAME Lodging in my primary language.
Other
Phone: 718-819-5235 5. Regular Payday: __________________ Print Employee Name
2. Notice given:
6. Pay is:
At hiring Employee Signature
Weekly
Before a change in pay rate(s), Bi-weekly
allowances claimed or payday Other: Date
DENNI HERRERA HR MANAGER
Note: Live-in employees must be paid at least
7. Overtime Pay Rate(s) for each type of Preparer’s Name and Title
13 hours for each 24 hour period, provided
work or shift:
they receive 8 hours of sleep, with five hours The employee must receive a signed
of uninterrupted sleep and 3 hours off for Single Pay Rate: $_______ per hour copy of this form. The employer must
meals. If an employee does not receive 5 This must be at least 1½ times the worker’s keep the original for 6 years.
hours of uninterrupted sleep, the employee regular rate with few exceptions. Please note: It is unlawful for an employee
must be paid for all 8 hours. If the employee with protected class status to be paid less than
does not receive meal periods free from duty, Wage Parity Pay Rate: $_______ per hour
This must be at least 1½ times the worker’s an employee without protected class status,
the employee must be paid for all 3 hours if they are performing substantially equal work.
designated for meals. regular rate with few exceptions.
Employers also may not prohibit employees
Multiple Pay Rates: $________ per hour from discussing wages with their co-workers.
This must be at least 1½ times the worker’s
Weighted average of the multiple rates of *Attach Wage Parity supplement notification
pay for the week, with few exceptions. page 2.
LS 62 (10/22) Page 1 of 2
LS 62 Notice to Wage Parity Home Care Aides - (cont’d)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation
Hourly Type of Name & Address Agreement/
Rate Supplement of Provider Plan Information
Identify plan or agreement that creates the
Insert Name and Address of
Supplement (Pension, Welfare, benefit, e.g., Union Local No. 1 Collective
$ XXX Company or Organization
Number or Other) Bargaining Agreement or Insurance
Providing Benefit
Company X Benefit Plan
Supplement CASTLE ROCK HC
20.34
Number 1
Supplement
Number 2
Supplement
Number 3
*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:
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.
My primary language is . I have been given this notice in my primary language Yes No.
Employee Name (Print):
Employee Signature: Date Signed:
DENNI HERRERA/HR MANAGER
Preparer’s Name and Title:
LS 62 (10/22) Page 2 of 2
