Payroll Correction Request Form
If you suspect an error has occurred on your payroll check, you must complete this form as soon as possible. The correction process will be completed within three working days of the date stamped on the form or is received by the office.
Employee Full Name
*
First Name
Last Name
Today's date:
*
-
Month
-
Day
Year
Today's date
Phone number where we can contact you if needed
*
Please enter a valid phone number.
Format: (000) 000-0000.
Type of Payroll Correction Needed
*
Missing hours
Incorrect overtime
Incorrect deductions
Other
Payroll date(s) in question
*
Example: 4/1 & 4/14. Enter hours worked below
Number of hours in question
*
Example: 2 hours of overtime and 4 hours of regular time
Client Name(s)
*
Describe the issue in detail
*
Example: My pay is missing two overtime hours from when I worked on Tuesday 7/19
How would you like to receive your pay for these missing hours:
*
Please adjust my next payroll check to reflect this correction
Please issue me a check that reflects this correction (if applicable)
Employee Signature
*
Submit Request
Submit Request
Should be Empty: