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Interactive Forms Manager
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Shippensburg Area
PAYMENT REQUEST - Extra Earnings
6/17/2019
Name: *
School: *
Employee ID: *
First 2 ltrs of last name, last 4 digits of SS#
Job: *
Supplemental Pay or Work Done for Extra Pay
Total Hrs or Total Days:
Hrly Rate, Daily Rate or Contract Amt: *
Total Pay:
Dates/Hrs of work:
not required for salaried supplementals

*** Below fields will be completed by payroll ****

Account Number:
Pay Date:
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