Payroll Discrepancy Submission Form

Date*
MM slash DD slash YYYY
Employee Name*
First Last
Employee Email*
Pay Period Start Date*
MM slash DD slash YYYY
Pay Period End Date*
MM slash DD slash YYYY
Check Number
Copy of Check Stub:
- Yes
- No
If yes, please attach a copy
Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.
Reason for Payroll Discrepancies
Check Problem Areas
- Pay Rate Incorrect
Paid Rate
Official Rate
- Wrong Amount of Hours
Straight Time
Overtime
- Wrong Deductions
- Equipment
- Training
Post
Start Time

: Hours

Minutes

AM/PM
End Time

: Hours

Minutes

AM/PM
Brief Explanation:*
Note: Upon receipt of this form, our office will investigate your complaint. If do, a check will be issued within five business days. If you have any questions or concerns, please contact us during business hours.

Reason for Payroll Discrepancies