REPORT OF OVERTIME State Form 47506 (R/10-03) /PYL 2617 Name of County County Number Class Code Name of Employee Social Security Number Salary Pay Period Beginning: Ending: Type of Overtime Normal Work Hours Day of Week Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total First 0.00 Week Second 0.00 Week CERTIFICATION BY EMPLOYEE I the undersigned, certify that the above-indicated time was spent in performing required functions. I understand that my current salary will be converted to an hourly rate and will be used as the basis for reimbursement. I further certify that the work I perform on this activity was done at a time other than during the regular working hours of the Indiana State Division of Family and Children. Date signed (month, day, year) Signature of Employee CERTIFICATION BY SUPERVISOR Approved and certified as true and correct to the best of my knowledge and belief. Date signed (month, day, year) Signature of Supervisor CERTIFICATION BY COUNTY DIRECTOR / SECTION DIRECTOR Approved and certified as true and correct to the best of my knowledge and belief. Date signed (month, day, year) Signature of County Director / Section Director NOTICE OF REQUIREMENTS: All details must be completed as state so that proper payment may be made to the employee in a timely manner. FAILURE to properly complete this form will result in a NON-PAYMENT and return of this form tom the LOCAL PAYROLL CLERKS for corrections.
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