Instructions for Completing State Work Study Time Sheet
Student: Complete the Student Section. For the “First day hours were worked enter the first day
(month/day/year) in this pay period on which you worked. For “Last day hours were workedenter the
last day (month/day/year) in this pay period on which you worked. Enter the number of hours you
worked under “Record of actual hours worked” next to the appropriate date. At the end of the pay
period, total the “Record of actual hours worked” and enter that figure on the “Total hours worked” line.
Read and sign the statement regarding your certification of the hours reported and your continued
eligibility for the State Work Study program. Be sure to date the form on or after the last day worked.
Give the form to your supervisor.
Employer: After paying the student the hours reported in the Student Section, type, or print in ink, all
information requested in the Employer Section. Read the employer’s certification statement, then sign
and print your name, and date the form (on or after the last day the student worked). Retain the pink
copy of the time sheet for your records. Forward the white and yellow copies to the student’s college for
processing. Important: Complete the time sheet accurately; any blank or incorrect items may delay
your reimbursement. Time sheets not forwarded to the student’s college within 15 days of the end of the
pay period may deny reimbursement.
College: Verify the information on the time sheet. Once verified, complete the College Section,
including institution code (from the list below). Retain the yellow copy of the time sheet for
institutional records. Forward the white copy to the Student Achievement Council for employer
reimbursement. Incomplete or late time sheets submitted to the Council can result in delayed or denied
reimbursement for employers.
INSTITUTION CODES (Council assigned)
3080
Antioch University
3130
Northwest University
3190
University of Puget Sound
3090
Bastyr University
3140
Pacific Lutheran University
3200
Walla Walla University
3100
Cornish College of the Arts
3150
Saint Martin’s University
3210
Whitman College
3110
Heritage University
3160
Seattle Pacific University
3220
Whitworth University
3120
Gonzaga University
3170
Seattle University
3490
Trinity Lutheran College
EXAMPLE
1. Student Section:
Student fills out entire
left side of time sheet.
2. Employer Section:
Employer completes top ¾
of right side of time sheet.
In order to receive prompt
reimbursement, ensure the
time sheet is completed
accurately and forward to the
college within the 15 days of
the end of the pay period.
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: $
0.00
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