# New York Wage Notice for Exempt Employees

## Employer and Pay Information

This notice states the employee’s pay rate and payday under New York Labor Law § 195(1). It supplements the offer letter. Use this form only after confirming the employee qualifies for an overtime exemption; payment of a salary alone does not establish an exemption.

This English-only form is for an employee whose primary language is English or for whom the Department of Labor provides no notice in the employee’s primary language. If the Department provides that language, use its official bilingual notice and acknowledgement instead.

Employer Legal Name
: {employer_name}

Doing Business As Names (or None)
: {employer_dba}

Employer Physical Address
: {employer_physical_address}

Employer Mailing Address
: {employer_mailing_address}

Employer Telephone
: {employer_phone}

Employee Name
: {employee_name}

Notice Given At Hiring or Before a Change
: {notice_reason}

Pay Rate and Basis (amount and period)
: {pay_rate_and_basis}

Allowances Claimed (None or type, amount and basis)
: {allowances}

Regular Payday
: {regular_payday}

Pay Frequency
: {pay_frequency}

Overtime Exemption (confirm applicability)
: {exemption_basis}

Employee Primary Language
: {primary_language}

Languages in Which This Notice Was Delivered
: {notice_languages}

Preparer Name
: {preparer_name}

Preparer Title
: {preparer_title}

## Notice and Delivery

### Delivery and Retention

Provide this notice at hiring. Give written notice of changes at least seven calendar days before the change unless the change is reflected on the wage statement, as provided in Labor Law § 195(2). If the employee’s primary language is not English and the Department of Labor provides a form in that language, use its official bilingual notice and acknowledgement. Otherwise, record the primary language and the applicable English-only basis below. Give the employee a signed copy and retain the signed acknowledgement for six years.

### Selecting the Appropriate Form

This independently authored form follows the subject matter of NYDOL LS59. Confirm applicable duties and salary requirements under both state and federal law; New York’s executive and administrative exemptions have regional salary thresholds above the federal floor. Check current requirements at https://dol.ny.gov/minimum-wage-frequently-asked-questions. It does not determine overtime eligibility or replace a required translation. For an employee who is not overtime-exempt, use the appropriate NYDOL pay notice, such as LS54 for an hourly employee or LS56 for a weekly salary covering a fixed number of hours. Official forms and translations are available at https://dol.ny.gov/notice-pay-rate and https://dol.ny.gov/LS59-doc.

## Employee Acknowledgement

I acknowledge receipt of notice of my pay rate, overtime treatment, allowances, and designated payday. I affirm that I accurately identified my primary language to my employer and that the primary language recorded above is correct. I received this notice in English because English is my primary language or the Department of Labor does not provide a notice in the primary language I identified.

Check the applicable statement before signing:

- [ ] English is my primary language, and I received this notice in English.
- [ ] My primary language is identified above. I received this notice in English because the Department of Labor does not yet provide a notice in that language.

My signature acknowledges receipt; it does not waive any employment right or establish that an overtime exemption applies.

Print Name: {employee_name}

Signature: _______________
Date Received: _______________

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