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Extra Duty Pay Request
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Date:
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Print Name - Pay to:
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Extra Duty Description:
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Date(s) of Duty Performed:
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Rate of Pay:$
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Hours or Days per Rate:
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Please Circle - that applies to rate* Total Amount:
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Account Name:
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Account Number:
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School/Building/Dept.
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Comments:
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Payee Signature:
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Supervisor Approval Signature:
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Supervisor Printed Name:
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* Please attach all supporting documents, bring to building secretary for approval by supervisor, and they will return to PAYROLL
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PAYROLL SIGNATURE
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