Claim For Salary or Wages For Part-Time Personnel

CLAIM FOR SALARY OR WAGES FOR PART-TIME PERSONNEL

Name*

Email*

example@example.com

Classification*

Employee #

For week ending:*

20*

Year

Position

Site*

District Department*

Business Department*

Maintenance Department*

Please fill out detailed hours worked below. When complete scroll to the bottom sign and submit form.

	Date	Site	Reason	Assignment	Start Time	End Time	Total Hrs/Day	Budget #
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16

Do you need to add multiple pay rates to this pay claim? (Example: A retired teacher who is substituting or long term substitutes)

YesNo

Days/Hours Rate of Pay 1

(example 2 days @ $120.00)

Days/Hours Rate of Pay 2

(example 2 days @ $200.00)

Do you want to split between two budgets?

YesNo

SPLIT BUDGET

	Total	Budget #
Split Budget 1
Split Budget 2

Gross Total HRS/DAYS*

Total hours claimed

Hourly Rate

Multiply hourly rate by total hours. If you do not know your hourly rate please leave blank.

GROSS SALARY EARNED (Sum of All Hours Worked at Applicable Pay Rates)

Claim total (Sum of All Hours Worked at Applicable Pay Rates)

I hereby certify that the above claim is true and correct and that no part thereof has been paid. All overtime was authorized in advanced. Payment made on 10th of the following month.

Employee Signature Signature* Employee Signature (Click on TYPE to type in signature)

Signature or Initial DO/Site Office Reviewed Please Initial or sign (Click on TYPE to type in your signature)

Signature Lead Administrator Signature (Click on TYPE to type in your signature)