Form Ccf-5 - Authorization For Extra Pay
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19998-500005
Clark County School District
ccF-5 r
. 9/03
ev
AuThORIzATIOn FOR ExTRA PAY
c
o
heck
ne
Date Received
In Personnel
Support Staff
(Page _____ of ______ )
Licensed
Unified
DATE SUBMITTED: _____________LOCATION: _____________________ # ____________
This will be your authorization to pay the employee/s listed below at the following designated rate of pay.
for: _____________________________________________________________________________________________
(DESCRIPTION OF SPECIAL SERVICE INCLUDING PROGRAM, IF APPLICABLE)
RATE OF PAY:
$20.00 per hour (Support Staff)
Contract hourly rate of pay
Contract daily rate of pay
$22.00 per hour
Substitute Pay
Overtime (support staff)
Other ________________
$ ___________
Responsibility Pay (Replacing: ______________________________
_________________
________
__________
If the request is for responsibility pay for a support staff employee, and if assignment is for less than 5 days, please
provide copies of prior responsibility request/s to verify the 5 day eligibility rule. (See Article 5 of the Agreement between
ESEA and the CCSD.)
B
u
F
Y
.
a
o
g
P
F
%
udget
nit
iscal
r
ccount
Bject
rant
roject
und
1 __________
___________ ___________
__________
__________
__________
__________
_________
c
2 __________
___________ ___________
__________
__________
__________
__________
_________
oding
3 __________
___________ ___________
__________
__________
__________
__________
_________
ALL PERSONS LISTED BELOW MUST HAVE SAME BUDGET CODING
(PER DAY)
(FOR TOTAL OF:)
PERSONNEL
NAME
SS#
DATE/S
MINUTES (OR) HOURS
MINUTES (OR) HOURS (OR) DAYS
USE ONLY
TOTAL:
TOTAL:
I certify that funds are available for this request.
unIT SuPERVISOR/PRInCIPAL:____________________________________________________ DATE: ______________________
DIVISIOn hEAD/DESIGnEE: _______________________________________________________ DATE: ______________________
PERSOnnEL ADMInISTRATOR/DESIGnEE: __________________________________________ DATE: ______________________
nOTE: FOR unIFIED OR LICEnSED PERSOnnEL TO BE PAID ON THE 25th, THIS FORM MUST BE RECEIVED IN PERSONNEL BY THE 1st OF THE MONTH. EXTRA
PAY FORMS FOR SuPPORT STAFF MUST BE RECEIVED IN PERSONNEL THREE (3) WEEKS IN ADVANCE OF THE ANTICIPATED PAY DAY.
DISTRIBuTIOn: FORWARD ALL COPIES (EXCEPT ORIGINATOR’S COPY) FOR APPROPRIATE UNIT/DIVISION SIGNATURES.
ORIGInAL/COPY: APPROPRIATE PERSONNEL DEPARTMENT
COPY: TO BE RETAINED BY BUDGET UNIT SUPERVISOR
COPY: TO BE RETAINED BY ORIGINATOR
031/032
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