PAYROLL DISCREPANCY FORM DATE:________
Fill this out before you do anything !
Directions: (1) Check the discrepancies which apply, and complete all relevant information below. (2) Make a
copy of this completed form to retain for your records. (3) Attach a copy of your check stub to this form (4 )
Attach timesheet with your corrections made, plus any other useful information, and turn the packet into the
mail slot labeled “Payroll Discrepancy.”. (5) PLEASE SIGN FORM AT BOTTOM.
You will have a written response within two business days of the submission of this form, which you can pick-up
from the Employee Communications Center. Errors of $49 gross pay or less will appear on your next regular
payroll check. Errors of $50 gross pay or more will be made up with a separate check to be distributed by Randy
Weiler. The separate check will be distributed before your next regular payroll check. Thank you.
NAME:_______________________________ CALLER NUMBER:_____________ PAYROLL DATE:________
TOTAL HOURS WORKED:
WEEK ONE_________ WEEK TWO_________
Amt. Paid: Should be $: Amt. Due: Amt.
Regular Hours Missing:_____hrs. week 1
_____hrs. week 2
Overtime Hours Missing:____hrs. week 1
_____hrs. week 2
Benefits Time Missing week 1
(Attach Pink Copy of Request)
Date(s):_____ _____hrs. week 2
BONUS Referral Bonus Missing:who
Extra Shift Bonus
Paid at Wrong Rate
No Check Issued TOTALS:
Employee Lost Check
PERSONAL INFORMATION ERRORS:
Address/Name/Telephone Correction Needed: W-4 Deductions Incorrect:
Current:_________ Should be:_________
_____________________________________________ Social Security Number:_______________
To Process: Place into PD Binder Pocket. When
staffing department completes the audit, sign the form
and DOUBLE-photocopy the discrepancy; forward the
SOURCE: ________PM ________SD _______PD
original to payroll if requires pay-out. Return
________DP ________FR _______Other photocopy to fund-raiser. File the remaining photocopy
in the PD Binder.
Comments:______________________________________________ APRVD By :________________________________