Form Py101 - Request For Copy Of Check Stub (Pay History)


Request for Copy of Check Stub (Pay History)
Cost: $5.00 per pay stub
If you would like payroll to provide you with a copy of your check stub information,
please do the following:
1) Go to the Payroll Office, Suite A, and pay $5.00 per pay stub history that you are
requesting. You may also mail this form to Payroll Services, along with a check made
payable to Palmdale School District.
2) Complete the following information:
Name: ___________________________ Social Security #: ______________________
School/Dept: __________________________ Job/Position: _____________________
3) List the specific pay dates that you are requesting a copy of:
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
4) Attach copy of the receipt from Payroll to this form and place form in the “Completed
Forms” tray in the Payroll Department.
Payroll will mail to you, the requested copies within 3 working days. Copies will be sent
to your current address on file. Should you need a change of address, please go to our
Human Resources Department to change your information.
I certify that I am the person for whom I am requesting pay information for and am either
a current or former employee of Palmdale School Distirct.
Signature _______________________________ Date _________________________
Form No: PY101


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Parent category: Business