Form LS14 "Notice and Consent for Payroll Debit Card" - New York

What Is Form LS14?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LS14 by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form LS14 "Notice and Consent for Payroll Debit Card" - New York

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Notice and Consent for Payroll Debit Card
Employer Information
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Employee Work Location: __________________________ Phone Number: _______________________
Methods of Payment
As a New York State employer, we can pay your wages in cash or check. This does not require your
approval. We may also pay your wages by direct deposit or payroll debit card. These forms of payment
require you to approve. If you do not approve, we will pay you in cash or check.
If you would like to receive your wages by payroll debit card, please read and sign below.
Notification of Payroll Debit Card Rights
If you are paid by payroll debit card, you must be given:
Local access. There must be one or more automated teller machines (ATMs) that offer
withdrawal at no cost to the employee within a reasonable distance from your place of
employment or your employee’s home.
Access to payment in full. There must be a place where you can withdraw up to the total
amount of your wages for each pay period or the balance on your payroll debit card without a
fee.
Addresses of local ATMs that will provide free
Locations where you may withdraw up to the
withdrawals:
total amount of wages or balance on the card:
______________________________
______________________________
Specified Address
Specified Address
Attached
Attached
______________________________
______________________________
Website
Website
You may not be charged fees for a payroll debit card by the employer or payroll card issuer for regular use of
the account. Prohibited fees include, but are not limited to: application fees, overdraft fees, maintenance fees,
and declined transactions fees at an ATM that does not provide free balance inquiries.
Payroll Debit Card Consent
On this day I have been notified of my options of payment methods. I give my consent to the above listed
employer to pay my wages through Payroll Debit Card. I have been informed of local ATM access with free
withdrawal.
________________________________________
______________________________________
Print Employee Name
Employee Signature
_______________________________
Date
LS 14 (1/17)
Notice and Consent for Payroll Debit Card
Employer Information
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Employee Work Location: __________________________ Phone Number: _______________________
Methods of Payment
As a New York State employer, we can pay your wages in cash or check. This does not require your
approval. We may also pay your wages by direct deposit or payroll debit card. These forms of payment
require you to approve. If you do not approve, we will pay you in cash or check.
If you would like to receive your wages by payroll debit card, please read and sign below.
Notification of Payroll Debit Card Rights
If you are paid by payroll debit card, you must be given:
Local access. There must be one or more automated teller machines (ATMs) that offer
withdrawal at no cost to the employee within a reasonable distance from your place of
employment or your employee’s home.
Access to payment in full. There must be a place where you can withdraw up to the total
amount of your wages for each pay period or the balance on your payroll debit card without a
fee.
Addresses of local ATMs that will provide free
Locations where you may withdraw up to the
withdrawals:
total amount of wages or balance on the card:
______________________________
______________________________
Specified Address
Specified Address
Attached
Attached
______________________________
______________________________
Website
Website
You may not be charged fees for a payroll debit card by the employer or payroll card issuer for regular use of
the account. Prohibited fees include, but are not limited to: application fees, overdraft fees, maintenance fees,
and declined transactions fees at an ATM that does not provide free balance inquiries.
Payroll Debit Card Consent
On this day I have been notified of my options of payment methods. I give my consent to the above listed
employer to pay my wages through Payroll Debit Card. I have been informed of local ATM access with free
withdrawal.
________________________________________
______________________________________
Print Employee Name
Employee Signature
_______________________________
Date
LS 14 (1/17)