Cell Phone and/or Internet Allowance Verification Form
This form is to verify the department’s election to provide an employee with a monthly allowance for
the use of his or her personal cell phone and/Internet service in accordance with SAM 03.A.19, Monthly
Communication Allowance for Business Use of Personal Cell Phone and/or Internet Service.
Please complete the information requested below and submit to Human Resources for record keeping
purposes.
Employee’s Name (Please Print): _________________________________________________________
PeopleSoft ID: _________________________
Job Title: ______________________________
Department: __________________________
Cell Phone Number: _____________________
Please select the type of allowance:
Cell Phone Service Only
Internet Service Only
Both
Please select the allowance amount:
$10.00
$25.00
$50.00
$75.00
Other (Specify Amount): __________
Employee Certification and Signature
I certify the acceptance of the above allowance and understand its purpose, continual receipt is
contingent on business need, and subject for review. I also certify that I have read, understood, and
intend to comply in accordance with SAM 03.A.19, Monthly Communication Allowance for Business Use
of Personal Cell Phone and/or Internet Service.
___________________________________
Employee Signature
______________________
Date
Manager and Department Head Certification and Signature
I certify that the above allowance is intended for the employee’s use of a personal cell phone and/or
internet service in order to fulfill his or her job duties. I also certify that I have read, understood, and
intend to comply in accordance with SAM 03.A.19, Monthly Communication Allowance for Business Use
of Personal Cell Phone and/or Internet Service.
___________________________________
Manager Signature
______________________
Date
___________________________________
Department Head Signature
______________________
Date
PLEASE ATTACH THE SIGNED FORM TO THE ePAR IN ORDER TO PROCESS THE ALLOWANCE.