WASHINGTON STATE WORK STUDY PROGRAM
TIME SHEET
Student Achievement Council 7/2012 (See instructions on reverse.)
STUDENT SECTION
1.
Last Name, First Name
2.
Social Security Number
3.
Name of College
4.
Job Title
5. First day hours were worked:
Month / Day / Year
6. Last day hours were worked:
Month / Day / Year
7. Record of actual hours worked:
01 16 _
02 17
03 18
04 19
05 20
06 21 _
07 22
08 23
09 24
10 25
11 26
12 27
13 28
14 29
15 30
31
8. Total hours worked: _
“I hereby certify this time sheet is a true and correct
statement of the hours I worked, and that I have State
Work Study eligibility to cover my gross earnings.”
9. _________________________________________
Student’s Signature
10. ___________
Date Signed (on or after last day worked)
EMPLOYER SECTION
Verify the information in the Student Section. Type, or
print in ink, all items requested in this section.
Submit the time sheet to the student’s college within 15
days from the end of the current pay period to prevent
denial of reimbursement.
You should receive reimbursement from the Student
Achievement Council within three to six weeks. An
incorrect or blank item may delay reimbursement.
11. Hourly rate of pay: $
12. Gross compensation: $
13. FICA: $
(Social Security & Medicare)
14. Other deductions: $
15. Net earnings: $
16. _____________________________________
Name of Business or Organization
17.
Employer Identification Number (EIN) Suffix
“This time sheet is a true and correct statement of
the time worked by this student. The student has
completed the assignment satisfactorily, continues
to have State Work Study eligibility, and has been
paid by check or direct deposit the amount of net
earnings as shown. I hereby certify, under penalty
of perjury under the laws of the state of
Washington, the foregoing is true and correct.”
18.
Supervisor’s Signature
Supervisor’s Name
19.
Date Signed (on or after student’s last day worked)
COLLEGE SECTION
20. Date received by college:
21. Authorized by:
22. Institution code:
23. Position number:
24. Reimbursement rate:
25. Reimbursement amount: $
