Prior Pay Period Adjustment Form

Office of Human Resources

HRIS PAYROLL ADMINISTRATION

Phone: (818) 677-2314

Fax: (818) 677-5870

Mail Drop: 8228

Prior Pay Period Adjustment Form
(Print this form in landscape format)
Do not use this form for Work-Study Student Pay Requests

Dept ID

Dept Name

Pay Period Month

Year

I. SELECT TYPE OF "PAY" TRANSACTION ADJUSTMENT:
Prior Month Pay	Hours Underpaid	Hours Overpaid
Request pay from a prior month when employee's hours were not included in regular transmission.	Report underpaid hours from a prior pay period.	Report overpaid hours from a prior pay period.

II. SELECT TYPE OF "LEAVE" TRANSACTION ADJUSTMENT:
Post Leave Usage	Correct Leave Usage	Delete Leave Usage
Post leave usage for a prior month when an employee's leave time was not recorded during the applicable period.	Correct leave usage for a prior month that was recorded incorrectly.	Delete leave usage for a prior month that was entered in error.

CSUN ID

Record #

Employee Name

Job Code

Date

Total Hrs*

TRC

Explanation of Adjustment (required information - please be as descriptive as possible)

* Total Hours. If total hours reported applies to leave usage for a period that covers more than one day, specify actual dates and hours applicable to those dates in the description box. Lump sum leave usage can not be processed.

I CERTIFY THAT THE INFORMATION ON THIS PAYROLL ADJUSTMENT FORM IS TAKEN FROM THE SPECIFIED TIMESHEET AND/OR ABSENCE REPORT FOR THE PAY PERIOD INDICATED, AND THAT THE TIMESHEET AND/OR ABSENCE REPORT HAS BEEN CERTIFIED BY SIGNATURE OF THE EMPLOYEE AND THE SIGNATURE OF THAT EMPLOYEE'S SUPERVISOR/MANAGER.
Note: Properly certified and signed timesheets must be maintained on file by the department for five (5) years.

Form Completed By (Print)

Date

Authorized Approver Signature _______________________

Print Name

Date

* Payroll Office Use Only *
Date:	Batch No:	Initials:	Total Hours:	Total Rate:	Agency: 253

SSN:

Class:

Serial:

EID:

Date Paid: