The weighted average is the total regular pay divided by the total hours worked in the week.
Overtime rate: it may vary from week to week depending on how many hours you worked at each rate of pay.
Employer information: Name, Doing Business As (DBA) name(s), FEIN (optional), Physical Address, Mailing Address and Phone.
Signed copy: the employee must receive a signed copy of this form.
Original: the employer must keep the original for 6 years.
| Question | Answer |
|---|---|
| Form Name | LS 55TL |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 47 |
| Avg. time to fill out | 8 min |
| Edition | 12/25 |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | LS 55TL, LS 55, LS55, Notice and Acknowledgement of Pay Rate and Payday, Multiple Hourly Rate Employees |
| Official source | LS 55TL (12/25), New York State Department of Labor |
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