Rev. 11/03 Payroll Services Division
On-Line Check Payment Request
DEPARTMENT ID: ______CHECK DATE:______
DEPARTMENT NAME:______DEPARTMENT TELEPHONE #_______
_____ON-LINE CHECK INFORMATION______
EMPLOYEE NUMBER: ______EMPLOYEE NAME: ______
Will employee be paid a regular check or direct deposit with standard deduction on the next cycle? YES_____ NO_____
Is this On-Line Check request the result of a check or direct deposit cancellation? YES_____ NO_____
If yes to Direct Deposit, was it stopped or reversed through Payroll Services or Treasury? YES_____ NO_____
If yes to above question, has clearance been given for On-Line Check to be issued? YES_____ NO_____
If clearance was given, by whom: Frank or Joanne (Please Circle)
Request Reason:
q Underpayment
q Overpayment
q No Pay/No Deductions
q Other (Explain)______
_____GROSS AMOUNTS______
Regular Earnings:
Regular Hours:______.______Hourly Rate:______.______Regular Salary:______.______
Other Earnings:
Earning Code Earnings Description No. Of Hours Rate Amount
______.______.______$______.______
______.______.______$______.______
______.______.______$______.______
______.______.______$______.______
______.______.______$______.______
______.______.______$______.______
______.______.______$______.______
______.______.______$______.______
Total Gross: [+] $______.______
_____TAXING INFORMATION______
Tax Status: M___ S___ Number of Exemptions: ______Extra Tax: $______.______
State Tax Filing Status: ___ Addition or Reduction to Withholding Amount: [+ or -] $______.______
Empl. Reg. Pay: Empl. has Deferred Comp/TSA: Federal Tax: $______.______
Biweekly: ___ Yes: ___ No: ___ FICA Tax: $ ______.______
Semimonthly: ___ State Tax: $______.______
Monthly: ___
Total Tax: [-] $______.______
_____DEDUCTION INFORMATION______
Deductions:
Deduction Code Deduction Description Deduction Amount
______$______.______
______$______.______
______$______.______
______$______.______
______$______.______
______$______.______
______$______.______
Total Deductions: [-] $______.______
______
Net: [=] $______.______
Total Credit Union Deduction Amount [+] $______.______
Adjusted Net Requested: [=] $______.______
_____DEDUCTION AUTHORIZATION______
I acknowledge receipt of this On-Line check in the amount of $______I understand that my credit union deduction is included in this check and it is my responsibility to deposit it to the credit union. The rest of my deductions will be paid to their appropriate vendors.
______
Employee Signature: ______Date: ______
______
Authorized Signature: ______Date: ______
______