No error, response/explanation provided.
Error confirmed as described above, requested remedy approved.
Error confirmed, except as specified below, requested remedy approved.
Other action taken, as follows:
Payroll Services Response Date:
Please print or type:
Employee ID
Period ending
Pay problem: Pay shortage Overpayment
Benefit deduction error Other
Explain pay problem:
Be as specific as possible, include earnings or benefit item in question & correction you believe is needed.
Remedy desired:
Apply adjustment(s) to next regular payroll
(For shortages, you will see a Retro earnings item for the amount of gross pay shortage on next pay stub.)
Issue check for additional net pay as soon as feasible
(As above, you will see a Retro for gross pay shortage added on next pay stub, but also a corresponding reduction to
net pay (“DrawRepay”) because the net amount owed was paid separately, prior to the payroll.)
Employee signature
Time submitted
Supervisor signature
Time submitted
Attach any additional documentation as may be necessary to verify pay issue or substantiate your request.
Scan/e-mail signed, completed forms To: and Cc: Include
in Subject “Notice of Pay Problem,” name of employee affected, and month in which it occurred. Signed
forms may also be submitted in person at City Hall.
Finance Staff Use Only
Request for Pay Correction
City and Borough of Wrangell