Payroll Adjustment Form

1
I am...* This field is required.
An employee filling this on my behalf
A supervisor submitting for an employee
2
Today's Date* This field is required.Requests made after Monday during a pay day week will not be paid until the FOLLOWING payroll.
Date
Year
Month
Day
3
Employee Name* This field is required.
First Name
Last Name
4
Supervisor Name* This field is required.
First Name
Last Name
5
Supervisor's Email* This field is required.Supervisor emails are first initial and last name @jolietymca.org. If unsure please use amaas@jolietymca.org
example@example.com
6
Reason for Pay Adjustment:* This field is required.
Missing Hours from a previous check
Pay Rate was incorrect
Other (please leave info in the comments below)
7
Missing Time worked but not paid out:* This field is required.For Unit staff please indicate Class time worked
Date Worked
Time Worked (please use am/pm)
Job Title Worked
1
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
2
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
3
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
4
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
5
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
6
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
1
2
3
4
5
6
Date Worked
Row 0, Column 0
Time Worked (please use am/pm)
Row 0, Column 1
Job Title Worked
Row 0, Column 2
Date Worked
Row 1, Column 0
Time Worked (please use am/pm)
Row 1, Column 1
Job Title Worked
Row 1, Column 2
Date Worked
Row 2, Column 0
Time Worked (please use am/pm)
Row 2, Column 1
Job Title Worked
Row 2, Column 2
Date Worked
Row 3, Column 0
Time Worked (please use am/pm)
Row 3, Column 1
Job Title Worked
Row 3, Column 2
Date Worked
Row 4, Column 0
Time Worked (please use am/pm)
Row 4, Column 1
Job Title Worked
Row 4, Column 2
Date Worked
Row 5, Column 0
Time Worked (please use am/pm)
Row 5, Column 1
Job Title Worked
Row 5, Column 2
1 of 6
8
Please explain the reason for the adjustment needed. Please be as detailed as possible.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
9
Please upload any supporting documents hereScreenshots or any supporting documents can be added here. Supervisors if you are filling the form out for the employee please remember to submit a green sheet if adding a job or changing a rate.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
10
I understand that this request will be processed with the next available payroll and that a separate check will not be issued without authorization from the payroll department* This field is required.For questions please email amaas@jolietymca.org
YESNO
Should be Empty: