STATE OF TENNESSEE REQUEST FOR SUPPLEMENTAL …



STATE OF TENNESSEE REQUEST FOR SUPPLEMENTAL PAYROLL

|1A |1 |

|Separation Date:    /    /      |Type of Supplemental: REGULAR- MAIN REGULAR –SPECIAL CREDIT WARRANT |

|2 |3 |4 |

|DEPARTMENT:      |WORK CENTER:      |DEPT / DIV:    .    |

|5 |6 |7 Beginning Date of |8 Ending date of |

|Name:      |Social Security No:     -    -      |Supplemental:    /    /    |Supplemental:    /    /    |

|9 | | | | | |

|Rate of Pay:       | | | | | |

| |Type of Earnings |Gross Earnings Due |Type |W/H |Obj. |

|19 Remarks:      | | |Department of Personnel Use Only: |

| | |Withholding |Employee due the following from Sick Leave Bank: |

| | |FICA | |

| | |Misc. Deduction | |

| | |NET | |

| | |Warrant Number | |

| | |Warrant Amount | |

|Agency Office |Dept. of Personnel |F&A Payroll |

|20 | | |

|Prepared by:      |Date Received: |Date Received: |

|21 | | |

|Date Released to Personnel:    /   /   |Date Released: |First: |

|22 | | |

|Budget Officer: |Commissioner: |Second: |

Form PR-0021 (rev 03-05) – Download form in MSWord format at

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