Payroll Change Form
:PAYROLL USE
ONLY:
Please be sure to complete all applicable information
Document Status:
Original or
Amended On
Hrs
Pers ________
By
Reason for Change
Sick ________
Resignation/Termination
End of Assignment (Inactive)
Retirement
Last Day Worked
Reactivate Assignment
Restructure
Job Re-evaluation
Compensation Change
*
O
R
Promotion
Demotion
Transfer
Other
Vac ________
 PPAIDEN
 PEAEMPL
 NBAJOBS
 PDABDSU/DEDN
 GXADIRD
 PEALEAV
 Address book
 Attendance
 HPS / PFL
 Timesheet sent
 LST waived
From (first day change is/was effective)
Through (last day change is/was effective)
*
Employee Name:
ID#
Employee Title:
School/Department:
Change Request(s)
From
To
$
$
Department
Supervisor
Job Title
Job Band
*Job Hours
*Wage/Salary Rate
*Overload
(1)
*Additional Compensation
(2)
*Account Number(s)
(use all 8 digits {xxxx-yyyy})
# of pays:
One
Multiple
Amount: $
# of pays:
One
Multiple
Amount: $
Acct:
-
%:
Acct:
-
%:
Acct:
-
%:
Acct:
-
%:
Acct:
-
%:
Acct:
-
%:
Other (explain)
*Affect Wage/Benefit Budget
If yes, please attach documentation as to how it will be funded
COMMENTS
Director/Dept Chair
Date:
Vice Provost / Dean
Date:
Provost/VP
Date:
VP for HR
Date:
*Controller
Date:
Print Name
Signature
Overload: [Faculty] – teaching-related pay (over 24 load units); [Non-faculty] – pay outside the normal scope of duties
Additional Compensation: compensation for other work (e.g., training, classroom speaking, bonus)
* Only changes made to categories marked with an asterisk require the signature of the Controller
(1)
(2)
HR Use Only:
612944620
FLSA Timesheet Required
Copies to:
HR
Benefits
Payroll
Provost/VP
Rev. 10/11