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RENUoil of America, Inc.
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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
Clear
Please note: Submission of form does not guarantee hours will be paid.
Submit
Thanks for submitting!
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