Payroll Corrections Form - 2-Sided Form

This form can only be used for more than one month if the changes are exactly the same for every month.

To: Sandy Letlebo Case Manager: Date:
Fax: 242-6266 Email:
Consumer Name:
Original Payment Information: (from payroll)
Special Needs Payroll: (check one please) Fiscal Agent Payroll:
Vendor Name:
Service Month(s):
SPC Number:
Units:
Account #:
$ Amount:

Corrections (Only complete items that need correction):

Service Month:
SPC Number:
Units:
Account #:

Correct Amount:

Difference/Credit amount (original payment minus correct amount):
***See other side/page 2 if more changes need to be made from original payment ***

This form should not be used for the exception report changes. (Except for service month changes)

Original Payroll Information Section: What was originally paid. Fill in the payment exactly as it appeared on your payroll.

Corrections: (Only complete items that need correction): This is what you want changed to make the payment correct.

Difference/Credit: Use this line when there is an amount change and then fill in page 2 of this form.

Reallocation of Difference/Credit to:
(fill in all lines top to bottom, use one column for each payment
that receives a portion of Difference/Credit from first page)
Service Month: / Service Month: / Service Month:
SPC Number: / SPC Number: / SPC Number:
Units: / Units: / Units:
Account #: / Account #: / Account #:
Original Payroll Pmt: / Original Payroll Pmt: / Original Payroll Pmt:
Difference/credit amount: / Difference/credit amount: / Difference/credit amount:
Total Correct Amount: / Total Correct Amount: / Total Correct Amount:

This form should not be used for the exception report changes.

Original Payment: What was originally paid or will be paid on payroll

Difference/Credit: What is subtracted or added from your original payment to reach the new amount (This should be the amount from the Difference/Credit on page 1 you want to move to this payment).

Total Correct Amount: Total amount paid including both the Difference/Credit on this form and any original payroll payment.

**Original Payroll payment plus Difference/Credit equals Total Correct Amount Owed/Paid**

For more detailed directions on filling out the Payroll Correction Form, please see separate instructions or contact Sandy Letlebo.

s:\HS\FMS\LTS\JSM – 10/16/2009

1