NOTE: Please use this form to request a Special Payroll Check for an employee who was not paid in their regular payroll cycle, either monthly or bi-weekly. Gross wages due must be $50 or greater. This request must be submitted by the 8 th of the month for monthly paid employees to receive payment on the 15 th . Requests must be submitted by Thursday noon for bi-weekly paid employees to receive payment on Friday after 1:00 pm.
Employee Name: Employee ID #:
Employee’s Time Roster #:
Special Payroll Check requested by:
Date of Request:
Phone No.:
Department:
Check fee is $25.00. Fee should be billed to Index: Account:
Reason for Special Payroll Check request:
Time card submitted after the deadline
Hiring document submitted after the deadline
Other (please explain in detail):
 Special payroll checks for monthly paid employees are available in the Human Resource
Services office, Lommasson 252, after 1:00 pm on the 15 th of the month. Special payroll checks for bi-weekly paid employees are available on Friday following payday after 1:00 pm.
Photo ID must be presented.
 Special payroll checks cannot be direct deposited.
 There is a $25.00 charge to the requesting department for this payment which is charged to the Index / Account provided above. Each time roster number is granted two requests for special payroll checks per fiscal year without charge.
______________________________________________ __________________
UM Employee Signature Date
Approval for Special Payroll Check request:
______________________________________________ __________________
Department/College Dean/Director Date
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HRS Payroll ONLY
Payroll data entry: __________ Accounting entry: __________
Updated 3/3/16