Ls 54 Form – Fill Out and Use This PDF

1. Employer Information

Name:

College of Staten Island

Doing Business As (DBA) Name(s):

FEIN (optional):

13-1616880

Physical Address:

2800 Victory Blvd.

Staten Island, New York 10314

Mailing Address:

Phone: 718-982-2030

2.Notice given:

□At hiring

□Before a change in pay rate(s),

allowances claimed or payday

LS54(06/20)

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

3.Employee’s rate of pay:

4.Allowances taken:

None

5.Regular payday: Thursday

6.Pay is:

□ Weekly

Bi-weekly

□Other

7.Overtime Pay Rate:

$ N/A per hour (This must be at least 1 ½ times the worker’s regular rate with few exceptions.)

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.

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

__________________________________

Date

Sharon Christian, Associate Director

Preparer’s Name and Title

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.