Payroll Discrepancy Form

Employee Name

Employee Phone Number

Discrepancy Concern:

Detailed description of hours and location worked for missing Pay Week:

Day 1:

Day 1: Date of Discrepancy

Day 1: Property

Day 1: Shift

Day 2:

Day 2: Date of Discrepancy

Day 2: Property

Day 2: Shift

Day 3:

Day 3: Date of Discrepancy

Day 3: Property

Day 3: Shift

Day 4:

Day 4: Date of Discrepancy

Day 4: Property

Day 4: Shift

Day 5:

Day 5: Date of Discrepancy

Day 5: Property

Day 5: Shift

Day 6:

Day 6: Date of Discrepancy

Day 6: Property

Day 6: Shift

Day 7:

Day 7: Date of Discrepancy

Day 7: Property

Day 7: Shift

Annual one time exemption:

I elect to use my annual one-time exemption which allows me to be paid for unverified hours with the understanding that payment without the proper sign-in/sign-out will accompany a written reprimand.

Photo of Paystub

Upload Photo of Paystub

Upload supported file (Max 15MB)

Employee Signature

Please note: Submission of form does not guarantee hours will be paid.

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