State Accounting Employee Payment Transmittal Form

STATE ACCOUNTING EMPLOYEE PAYMENT TRANSMITTAL FORM

____ Refund From Employee _____Void Check ___ Direct Payment from Employee

(please check one)

EMPLOYEE NAME______

EMPLOYEE ID NUMBER ______ID NUMBER______

AMOUNT OF REFUND (Net Pay) ______

VOID CHECK CHECK NUMBER ______

AMOUNT OF DIRECT PAY: Total Amount Paid by Employee ______

DBA Codes Amount

(ATTACH CHECK HERE)

Explanation of Transaction ______

______

PROCESSED THROUGH:

_____INTERIM ____REGULAR PAYROLL

SPECIFY PAYROLL _____(i.e., B01, M01)

AUTHORIZED AGENCY CONTACT ______

(please print)

AGENCY NAME AND NUMBER ______

AUTHORIZED AGENCY CONTACT SIGNATURE: Phone No.

______