Fillable Verification-of-Services---Print-on-Goldenrod - Verification of Services

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Verification-of-Services---Print-on-Goldenrod - Verification of Services

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Form to be completed by the department requesting the stipend and submitted directly to Payroll. Please print on
Goldenrod colored paper. For questions please contact Payroll at 626.585.7451
PCC VERIFICATION OF SERVICES FORM, Revised 10/03/14: LOCATION (W) DRIVE, FORMS
Verification of Services
Last Name First Name Initial EID #
Authorization for Payment
Certificated Services
Consent Item Number: _______________________Date of Consent Item: ______________
FOAP (Account Number):
__________________________________________________________________
Fund
(6)
ORG
(6)
Account
(6)
Program
(4)
Payment for the month of: _____________year of: _________
Payment #: ________of: _________
*Amount of Payment:
Authorized Signature: ___________________________________Date: _____________
Brief explanation of services performed:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
*Paid on next regular pay cycle
-Payroll Internal Use Only-
Payroll Tech: ___________
Issue Date: _____________
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Verification-of-Services---Print-on-Goldenrod - Verification of Services

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Completed 4 January 2020

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