FEDERAL WORK-STUDY EMPLOYMENT PROGRAM by wbc12688

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									                                            Payroll Action From (PAF)
                                          (Federal Work-Study Program)


I. TO BE COMPLETED BY STUDENT (PLEASE PRINT CLEARLY and USE BLACK OR BLUE INK)


__________________________          ___________________________ _____                   _________-______-___________
Legal Last Name                     Full First Name             M.I.                    Federal SSN

I understand: (a) I must be a currently enrolled student at UTHSC to be eligible for FWS funds; (b) I will be
terminated from the FWS Employment Program if I do not adhere to all the procedures and conditions of employment;
(c) Section II and Form I-9, Form W-4 must be completed by my employer and returned to the Financial Aid Office for
approval prior to my beginning work; (d) my employment is not completed until I have submitted the Direct Deposit
Authorization Form.(e) I understand that if my timesheet is turned in late or without all required signatures I will
be paid on the next pay date after time was turned in late.

I verify that I have read and understand the above statement.

_________________________________________________________________                        ________________________
Authorized Signature                                                                     Date

II. TO BE COMPLETED BY DEPARTMENT (PLEASE PRINT and USE INK)

Dept/Agency. Name _____________________________________________Phone # ___________________________

Dept./Agency Address _____________________________________ Fax # ____________________________

Period of Employment _________________ to _________________ Form I-9 attached? Yes ( ) No ( ) If no, reason

Acct. Number to be charged ________________________________ Rate of Pay $ ___________ (minimum is
$10/hour on campus $15/off campus)

I certify that funds have been budgeted in this department for 25% of the student’s earnings. I understand: (a)
employment will be in accordance with University procedures, as well as Federal and State laws; (b) the student
cannot work in this department until this Payroll Action Form, Form I-9, Form W-4, and the Direct Deposit
Authorization Form have been completed and returned for approval by the Student Financial Aid Office; (c) I
understand that if time sheets are turned in late or without all required signatures the student will be paid on the next
pay date after time was turned in late. Timesheets are to be faxed to 901-448-7772 by noon Monday following the
end of the pay period.

_________________________________________________________________                        ________________________
Authorized Signature                                                                     Date

III. JOB ASSIGNMENT INFORMATION (To be completed by Work-study coordinator) 448-5568

Total Dollar Amount Awarded $__________________                 Balance Available $____________________

_________________________________________________________________                        ________________________
Authorized Signature                                                                     Date

IV. TO BE COMPLETED BY Bonnie Vandergriff 910 Madison Suite 520                        448-5568

Load _____________ Previously Loaded _________________ Federal Account No. ___________________________

Hours Enrolled _________

Approved to Begin Work on __________________ to ___________________                Hourly Pay Rate $_____________

_________________________________________________________________                        ________________________
Authorized Signature                                                                     Date


     Return form with original signatures to: Office of Enrollment Services
                                              910 Madison Ave., Suite 525
                                                      Memphis, TN 38163

								
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