Payroll Status Change Form

PAYROLL STATUS CHANGE

EFFECTIVE DATE

_______/______/____

NAME: _______________________________________ PAYROLL #: ____________

CHANGE
FROM
TO

POSITION

HOURS

PA

CENTER

BENEFITS

OTHER

REASON FOR CHANGE

EXTENDED INTRODUCTION 30 DAY EVALUATION DISCIPLINARY ACTION

CHANGE IN LOCATION HOURS INCREASE/DECREASE

TRANSFER FMLA UNPAID LEAVE

PA CHANGE CHANGE OF ADDRESS/NAME OTHER

COMMENTS, IF NECESSARY:

NEW ADDRESS/NAME

^Street

^{City, State, Zip}

^Telephone

REQUESTED BY: ______________________________ DATE: ________________

AUTHORIZED BY: ______________________________ DATE: ________________

APPROVED BY: ________________________________ DATE: _________________

COPIES TO:

1. PERSONNEL 2. PAYROLL 3._______________ 4. PROGRAM DIRECTOR 5. SUPERVISOR

Last updated on February 28, 1998

CHANGE	FROM	TO
POSITION
HOURS
PA
CENTER
BENEFITS
OTHER

NEW ADDRESS/NAME	^Street
	^{City, State, Zip}
	^Telephone