Form LS 55TL at a glance
What it is: This form is the Notice and Acknowledgement of Pay Rate and Payday under Section 195.1 of the New York State Labor Law, a Notice for Multiple Hourly Rate Employees.
Who signs: Fill in Print Employee's Name and Date, and sign Employee's Signature. The employee must receive a signed copy of this form. The employer must keep the original for 6 years.
A filled-in Form LS 55TL example: an employer gives a new hire the notice
How to fill out Form LS 55TL, box by box
1. Employer Information
Under 1. Employer Information, fill in Name, Doing Business As (DBA) name(s), FEIN (optional), Physical Address, Mailing Address and Phone.
2. Notice given
For 2. Notice given, check At hiring or Before a change in pay rate(s), allowances claimed or payday.
3. Employee's rate(s) of pay for each type of work or shift
Under 3. Employee's rate(s) of pay for each type of work or shift, enter $ per hour for each type of work or shift.
4. Allowances taken
Under 4. Allowances taken, check None, or fill in Tips: per hour, Meals: per meal, Lodging or Other.
5. Regular payday
Fill in 5. Regular payday.
6. Pay is
For 6. Pay is, check Weekly, Bi-weekly or Other.
7. Overtime Pay Rate(s) for each type of work or shift
7. Overtime Pay Rate(s) for each type of work or shift must be at least 1½ times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week.
8. Employee Acknowledgement
8. Employee Acknowledgement: On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given in Date.
Check one: I have been given this pay notice in English because it is my primary language, or write your primary language after My primary language is and check that you 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.
Fill in Print Employee's Name and Date, and sign Employee's Signature.
Fill in Preparer's Name and Title.
Sources
[1] Form LS 55TL (12/25), Notice and Acknowledgement of Pay Rate and Payday, New York State Department of Labor (the Official source link on this page).