Pay Stub Request Form

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To request a copy of a pay stub, you must complete this form and mail it to KimstaffHR 17872 Cowan Avenue, Irvine,
CA 92614 Attention: KimstaffHR, Inc. Payroll. Include a check or money order for $5.00 per copy. Pay stub copies
will not be sent unless fee is included.
List pay stub dates requested: _________________________________________________________________
__________________________________________________________________________________________
EMPLOYEE INFORMATION:
Worksite Employer: ___________________________________________________________________
Employee Name: _____________________________________________________________________
SSN: _______________________________________________________________________________
Current Street Address: ________________________________________________________________
City _______________________________________________ State ____________ Zip ____________
Contact Phone Number: _________________________________________
Email Address:_________________________________________________
_____________________________________________________________________ _________________
Employee Signature
Date
Pay stub requests will be mailed (USPS First Class) within 3 business days of the receipt of the request.
PAYROLL DEPARTMENT USE ONLY:
DATE RECEIVED ____________
PROCESSED BY ____________

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