Payroll Change Request Form

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PAYROLL CHANGE REQUEST FORM
Reset Form
Court Packet #
Signed original to the County Auditor by Tuesday at 8:00 A.M. before
the Monday Commissioners Court at which it is to be approved.
EMPLOYEE NAME:
EMPLOYEE NO:___________________________________
JOB TITLE:
DEPARTMENT NAME/NO.:
REQUESTOR:
EFFECTIVE DATE:
(TO BE COMPLETED BY THE REQUESTING DEPARTMENT)
CHECK APPLICABLE BOXES
FROM
TO
DEPARTMENT
JOB TITLE
HOURLY
BI-WEEKLY BASE RATE
$
$
BI-WEEKLY:
AUTO $
DEPUTY LONGEVITY $
CERTIFICATION PAY $
TOTAL HOURLY/BI-WEEKLY PAY ____________________ (do not add auto)
EMPLOYEE STATUS:
REGULAR
TEMPORARY
FULL TIME
PART TIME
REPLACEMENT FOR
OR
NEW POSITION
REASON FOR CHANGE (S):
HIRED
LAID OFF
JOB RE-EVALUATED
RE-HIRED
RETIRED
MERIT INCREASE
PROMOTED
DECEASED
PROBATIONARY PERIOD COMPLETED
DEMOTED
STATUS CHANGE
PAID FMLA/DISABILITY LEAVE
TRANSFERRED
CORRECTION
UNPAID FMLA/DISABILITY LEAVE
RESIGNED
BRIDGE TIME
RETURN FROM PAID/UNPAID FMLA/
DISCHARGED
UNPAID LEAVE OF ABSENCE (NON-
DISABILITY LEAVE
MEDICAL) from _______ to ______
OTHER
(TO BE COMPLETED BY HUMAN RESOURCES)
HOURS DUE AT SEPARATION
DATE OF HIRE
JOB GRADE
COMPA-RATIO ____%
VACATION
MINIMUM
MIDPOINT
MAXIMUM
SICK LEAVE*
POSITION IS NOT COVERED BY CIVIL SERVICE
COMPENSATORY TIME
POSITION IS COVERED BY CIVIL SERVICE EFFECTIVE
HOLIDAY TIME
AUTO PAY
*Only grandfathered sick leave will be paid at
BENEFIT ELIGIBILITY: TCDRS
MEDICAL/LIFE, ETC.
time of retirement (eligible under TCDRS)
YES
YES
NO
NO
(TO BE COMPLETED BY THE COUNTY AUDITOR)
CURRENT FY BUDGETED AMOUNT
SALARY ANNUALIZED
_____ ANNUAL BUDGETED HOURS _____
FY
BUDGET WILL INCREASE BY
SOURCE OF FUNDING
BUDGET AMENDMENT WILL BE NEEDED IN THE AMOUNT OF ___________ REVIEWED BY COUNTY AUDITOR
DATE APPROVED BY COMMISSIONERS COURT:
________ __________ __________
__________
__________
CO JUDGE COMM PCT#1 COMM PCT#2 COMM PCT#3 COMM PCT#4
DO NOT MODIFY THIS FORM
I:FORMSPCRF Revised A 11.21.07.doc /

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