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 withdrawals:

Locations where you may withdraw up to the total amount of wages or balance on the card:

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______________________________ Specified Address

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______________________________ Specified Address

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Attached

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Attached

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______________________________ Website

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______________________________ 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 _______________________________ Date

LS 14 (1/17)

______________________________________ Employee Signature