Notice and Acknowledgement of Pay Rate and Payday New York City (NYC)

Under Section 195.1 of the New York State Labor Law (English)
for Home Care Aides Wage Parity and Other Jobs

3. Employee’s Rate(s) of Pay for 8. Employee Acknowledgement:

1. Employer Information Each Type of Work Shift: On this date, I have been notified of my pay rate,
$ 20.00 per hour for Mon-Fri overtime rate (if eligible), allowances, supplements
Consumer:
and designated payday. I told my employer what my
$ 20.50 per hour for Sat-Sun
JAYA WELINGTON $ per hour for
primary language is.

Last Name First Name Check one:

3a. Wage Parity Rates:
$ 20.00 per hour for regular wage
 I have been given this pay notice in English,
Mailing Address:
because it is my primary language.
$ 1.08 per hour for additional wage
55-25 98TH STREET #6D $ 0.08 per hour for supplemental wages*  My primary language is Spanish .
Address Apt. I have been given this pay notice in English only,
4. Allowances: because the Department of Labor does not yet
CORONA NY 11368  None offer a pay notice form in my primary language.
 Tips per hour
City State Zip Code
 Meals per meal
VELEZ YANZA ANGELICA
 Lodging ^ Employee - Last Name First Name
2. Notice given:  Other
 At hiring 5. Regular Payday: Friday ^ Employee Signature
 Before a change in pay rate(s),
6. Pay is: 01-12-2024
allowances claimed or payday
 Weekly ^ Date
Note: Live-in employees must be paid at least  Bi-weekly
13 hours for each 24-hour period, provided they  Other: Concepts of Independence, Inc. – Fiscal Intermediary
receive 8 hours of sleep, with five hours of ^ Preparer’s Name and Title
7. Overtime Pay Rate(s) for each
uninterrupted sleep and 3 hours off for meals.
type of work or shift: The employee must receive a signed copy of
If an employee does not receive 5 hours of
uninterrupted sleep, the employee must be Single Pay Rate: $ 30.00 per hour this form. The employer must keep the
paid for all 8 hours. If the employee does not This must be at least 1½ times the worker’s original for 6 years.
receive meal periods free from duty, the regular rate with few exceptions.
Please note: It is unlawful for an employee with
employee must be paid for all 3 hours Wage Parity Pay Rate: $ 30.00 per hour protected class status to be paid less than an
designated for meals. This must be at least 1½ times the worker’s employee without protected class status, if they are
regular rate with few exceptions. performing substantially equal work. Employers also
may not prohibit employees from discussing wages
Multiple Pay Rates: $ ------------ per hour
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 page 2.
pay for the week, with few exceptions.

Wage Notice LS 62 (1/2 Pgs.) v23.12 Page 1 of 2

 LS 62 Notice to Wage Parity Home Care Aides - (cont’d) New York City (NYC)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation (English)

Supplement Hourly Type of Name & Address Agreement/

Number Rate Supplement of Provider Plan Information
Supplement Life Insurance/AD&D Unum Life/Disability
$0.03 All Aides
Number 1 Supplemental disability www.unum.com
Supplement 1199SEIU Training Training-and-education/
$0.05 All Aides
Number 2 & Education Fund www.1199seiubenefits.org/

*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 contacting:

Concepts at 212-293-9999 Ext. 209, or Fax 888-418-4014, or email [email protected]

_____________________________________________________________________________________________________________________________

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 addendums, on the date given below.

My primary language is Spanish . I have been given this notice in my primary language  Yes  No
VELEZ YANZA ANGELICA
Employee Name (Print):
Last Name First Name

Employee Signature: Date Signed: 01-12-2024

Preparer’s Name and Title: Concepts of Independence, Inc. – Fiscal Intermediary

Wage Notice LS 62 (2/2 Pgs.) v23.12 Page 2 of 2