Payroll Adjustment Form

A payroll adjustment form is used by employees who have different salary scales. This form should be used to submit adjustments for specific types of earnings that require authorization and verification by the HR. The adjustments are made according to the type of pay the employee wants to adjust and the description of the pay.  Below is a sample payroll adjustment form.

Sample Payroll Adjustment Form

I (employee’s name) __________________________________________

for the pay period (indicate pay period) ________________________________.

of the employment record (indicate here) ________________________________

for service dates _____________

Having held the position of (indicate position) ______________________________

I hereby state that the payroll contact is as follows _____________________________________________________________

and the biweekly salary is stated as follows_____________________________________________________________

I (employee) can be reached on this contact number _____________________________________________________________

(Details of the adjustments to be made.)

For the tax period (indicate period) _____________________________________________________________

in this department (indicate department) _____________________________________________________________

I would like to make adjustments on (indicate which pay) _____________________________________________________________

for (furnish details of adjustments) _____________________________________________________________

for the amount of (amount in dollars) _____________________________________________________________

having worked for (indicate number of hours) _____________________________________________________________

I would like these adjustments to be effected immediately.

Signed (employees signature) _____________________________________________________________

Date _____________________________________________________________

Approved by (departmental head) _____________________________________________________________

Date _____________________________________________________________

Category: Payroll Forms