Payroll Correction Form

Name of employee*

FirstLast
Date worked*

MonthDayYear
Date
In Time*

:HourMinutesAM/PM Option
Out Time*

:HourMinutesAM/PM Option
Number of Hours Owed*
Bill wages to Department*
Pay Rate*

Regular Pay RateRate DifferentialOther
Express Check*

YesNo
Include this time with the next regular paycheck*
Describe the reason for this payroll correction:*
Supervisor Submitting Request:*

First NameLast Name
Should be Empty: