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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