Authorization To Compensate Form

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GREAT NECK PUBLIC SCHOOLS - AUTHORIZATION TO COMPENSATE
TO:
PAYROLL DEPARTMENT
FROM:
DATE:
DIRECTIONS: This form is used to authorize payment for additional services performed by an employee. Please send to Payroll after work is completed.
I.
Employee Information:
Name: ________________________________________________________________
SS#/ID#: _______________________________
Position: ______________________________________________________________ Location: _______________________________
II.
Reason For Payment And Time/Rate To Be Paid: Add additional lines on back of form if needed
Reason for payment: Use the appropriate service code(s) to complete the chart below. Please use the explanation line below to provide any additional details.
1 - Activities/Clubs
5 - Differential Payments
9 - Meetings
13 - Phys Ed
17 - Test Proctoring
(incl. collaborative)
(e.g. intramurals)
2 - Adult Education
6 - Enrichment Course
10 - Mentoring
14 - Recreation
18 - Translating
3 - Athletics
7 - Homework Center
11 - Parent-Teacher Conference
15 - Summer Work
19 - Tutoring
(e.g. coach, crowd
supervisor)
4 - Classroom Preparation
8 - Inservice Course
12 - Perfect Attendance Stipend
16 - Temporary Assignment
20 - Other (explain below)
Service
Date(s) of Service
Time (from - to)
Total
Rate
Total Pay
Budget Code
Code
Hours
-
-
-
-
-
-
Explanation: ______________________________________________________________________________________________________________________
III.
Certification/Authorization: Form must be signed and sent to Payroll for payment to be made.
This is to certify that the services claimed above have been performed for the Great Neck Union Free School District, and that said claim is just, due and unpaid.
Employee Signature: ______________________________________________________________________
Date: ____________________
This is to verify that the services claimed above were rendered and payment is now due to the employee.
Authorizing Signature: ____________________________________________________________________
Date: ____________________
Additional Authorizing Signature (if needed): __________________________________________________
Date: ____________________
REV. 01/06

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