ELIZABETH CITY STATE UNIVERSITY
ELIZABETH CITY, NORTH CAROLINA 27909
Supplemental Pay for Services Rendered for EPA Employees
Note: This form should be used to pay for services in addition to the regular work assignment.
Services rendered must not interfere or conflict with the primary duties.
NAME: _____________________________________________________________________________________________________________
SCHOOL/DEPT: ____________________________________________________________________________________________________
DIVISION/UNIT____________________________________________________________________________________________________
DEPARTMENT/UNIT REQUESTING SERVICES ______________________________________________________________________
BEGINNING DATE ______________________________________
ENDING DATE _________________________________________
DESCRIPTION OF DUTIES __________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
ANTICIPATED NUMBER OF HOURS TO BE WORKED: _____________
Project Director Signature: ______________________________________________________ Date: _______________________________
Budget Code: _______________________________ G/L Account #: _______________________________________________________
Grant Title (if applicable):__________________________________________________________________
METHOD OF PAYMENT
**TIME SHEETS (IF APPLICABLE) SHOULD BE SUBMITTED TO HUMAN RESOURCES AND PAYROLL**
SUM OF PAY $__________________, BEGINNING _________________ AND ENDING ________________ IN _________ EQUAL INSTALLMENTS
SUM OF PAY $__________________, PAYABLE ON ____________________________________________________________________________________
HOURLY PAY RATE ____________________________ X __________________________ = $ ______________________________
Hours Worked
**TO BE COMPLETED BY HUMAN RESOURCES**
TIME AND EFFORT PERCENTAGE: ____________
HR VERIFICATION:________________
AS OF
___________________
DATE
BUDGET
Approved Salary $___________________________________________
APPROVALS
___________________________
Employee’s Supervisor
_________________
Date
___________________________
Vice Chancellor/Unit Head
_________________
Date
________________ __________
Vice Chancellor/Human Resources
_________________
Date
Funding Source ___ Federal ___State ____ Auxiliary ___ Other
Authorized by: ______________________________________________
Division of Business and Finance
Date: ________________________________________________________
______________________________________________________________
Sponsored Programs (If Applicable)
Date