Exempt Staff Supplemental Pay Authorization Form
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employe r
Primary Position #
________________
o fc hoi c e
Secondary Position #:
________________
Log #:
________________
Name______________________________________________________________________________ RIN#___________________
Title________________________________________________________________ Primary Department/Org.__________________
Department/Organization for which work is being performed (Secondary):_______________________________________________
Terms of assignment (Including Title, if any):______________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Dates and times work will be performed (must be outside regular work schedule):__________________________________________
___________________________________________________________________________________________________________
Supplemental Work Schedule (Days of Week and Times)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Amount to be paid (include calculations used to determine amount of payment):____________________________________________
____________________________________________________________________________________________________________
Position and Labor Distribution Information for Supplemental Pay
Fund
Organization
Account
Program
Activity
Authorized $
Hours
All signatures on this document are affirming that the supplemental work will not negatively affect the employee’s regular job, responsibilities,
schedule, or quality of work and will be performed in addition to the employee’s 100% effort at his or her regular job.
___________________________________________________
________________________________________________
Employee Requesting Payment
Date
Secondary Dept. Immediate Supervisor
Date
___________________________________________________
________________________________________________
Primary Dept. Immediate Supervisor
Date
Secondary Dept. Head/Director
Date
___________________________________________________
________________________________________________
Primary Dept./Next Level of Supervision
Date
Secondary Portfolio Business Manager
Date
___________________________________________________
________________________________________________
Primary Portfolio Owner
Date
Secondary Portfolio Owner
Date
NOTE: This form must be submitted to Human Resources, with all required signatures, for review and approval. The assignment cannot
commence until the request has been approved by Human Resources. Once approved, the approved form will be forwarded to Payroll
and a copy will be forwarded to the Secondary Department. The Secondary Department is responsible for ensuring that the work takes
place as planned, and should contact HR immediately if any of the above information changes to prevent overpayment.
Human Resource/Payroll Information
SM
SUPP
O
0.0
E
Position#
Pay Type
Job Change Reason Code
Primary/Overload
Job FTE
Exempt/ Non-Exempt
(Supplemental Job)
Payment shall be paid as:
Lump Sum
Over Contract Period (Teaching Only)
HUMAN RESOURCES____________ DATE_____________
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