Online Check Request Form - Core-CT
Rev. 11/03 Payroll Services Division
On-Line Check Payment Request
DEPARTMENT ID: ___________ CHECK DATE:____________________________
DEPARTMENT NAME:________________________________________________ DEPARTMENT TELEPHONE #________________
_____ON-LINE CHECK INFORMATION_______________________________________________________________________________
EMPLOYEE NUMBER: ___ ___ ___ ___ ___ ___ ___ EMPLOYEE NAME: _____________________________________________
Will employee be paid a regular check or direct deposit with standard deduction on the next cycle? YES_____ NO_____
Is this On-Line Check request the result of a check or direct deposit cancellation? YES_____ NO_____
If yes to Direct Deposit, was it stopped or reversed through Payroll Services or Treasury? YES_____ NO_____
If yes to above question, has clearance been given for On-Line Check to be issued? YES_____ NO_____
If clearance was given, by whom: Frank or Joanne (Please Circle)
Request Reason:
❑ Underpayment
❑ Overpayment
❑ No Pay/No Deductions
❑ Other (Explain)____________________________________________________________________________________________
_____GROSS AMOUNTS__________________________________________________________________________________________
Regular Earnings:
Regular Hours:___ ___ ___.___ ___ Hourly Rate:___ ___.___ ___ ___ Regular Salary:___ ___ ___ ___ ___ ___.___ ___
Other Earnings:
Earning Code Earnings Description No. Of Hours Rate Amount
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
________ __________________ ___ ___ ___.___ ___ ___ ___.___ ___ ___ ___ $___ ___ ___ ___ ___.___ ___
Total Gross: [+] $___ ___ ___ ___ ___ ___.___ ___
_____TAXING INFORMATION_______________________________________________________________________________________
Tax Status: M___ S___ Number of Exemptions: ___ ___ Extra Tax: $___ ___ ___.___ ___
State Tax Filing Status: ___ Addition or Reduction to Withholding Amount: [+ or -] $___ ___ ___.___ ___
Empl. Reg. Pay: Empl. has Deferred Comp/TSA: Federal Tax: $___ ___ ___ ___ ___.___ ___
Biweekly: ___ Yes: ___ No: ___ FICA Tax: $ ___ ___ ___.___ ___
Semimonthly: ___ State Tax: $___ ___ ___ ___ ___.___ ___
Monthly: ___
Total Tax: [-] $___ ___ ___ ___ ___.___ ___
_____DEDUCTION INFORMATION____________________________________________________________________________________
Deductions:
Deduction Code Deduction Description Deduction Amount
___________ ______________________________ $___ ___ ___ ___ ___.___ ___
____________ ______________________________ $___ ___ ___ ___ ___.___ ___
____________ ______________________________ $___ ___ ___ ___ ___.___ ___
____________ ______________________________ $___ ___ ___ ___ ___.___ ___
____________ ______________________________ $___ ___ ___ ___ ___.___ ___
____________ ______________________________ $___ ___ ___ ___ ___.___ ___
____________ ______________________________ $___ ___ ___ ___ ___.___ ___
Total Deductions: [-] $___ ___ ___ ___ ___.___ ___
___________________________
Net: [=] $___ ___ ___ ___ ___.___ ___
Total Credit Union Deduction Amount [+] $___ ___ ___ ___ ___.___ ___
Adjusted Net Requested: [=] $___ ___ ___ ___ ___.___ ___
_____DEDUCTION AUTHORIZATION__________________________________________________________________________________
I acknowledge receipt of this On-Line check in the amount of $______________ I understand that my credit union deduction is included in this check and it is my responsibility to deposit it to the credit union. The rest of my deductions will be paid to their appropriate vendors.
_________________________________________________________________________________________________________________
Employee Signature: _________________________________________________ Date: ___________________________
__________________________________________________________________________________________________________________
Authorized Signature: ________________________________________________ Date: ___________________________
__________________________________________________________________________________________________________________
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