MILITARY DIFFERENTIAL PAY REQUEST FORM
Name ___________________________________
Employee ID (EID)
_____________________
(Last, First, MI)
Staff
Faculty
Administrator
Professional
Primary Title: ____________________________________________________
FTE: __________
Dept. Name: ____________________________________________________
Dept. #: ________
Active Military Duty - Start Date:
Last date of paid military leave:
________________ End Date: ____________________
________________
Military Differential Pay Request - Start Date: ___________ End Date: ____________________
(Note: The beginning of the “Military Differential Pay” is different from the beginning of the active military duty, since an
eligible employee must exhaust his/her military leave before the start of Military Differential Pay.
Rate of Pay prior to the start of the Military Differential Period:
_____________________
Projected Military earnings and allowances:
_____________________
annual / hourly (circle one)
The following documents must be attached:
- Proof of Honorable Military Discharge (DD-214, DD-220, DD-256 and/or a similar
document
- Military Leave and Earnings Statement (LES) or equivalent military document
Employee Signature: ____________________________________________________
Authorizing Signature: ___________________________________________________
Please submit completed form and attached documentation to:
Name: _____________________
Email: _____________________
Fax: _______________________
Phone: _____________________
Address: ____________________
The University System of Georgia
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