Payroll Handcheck Requisition

Check Amount $ ___________

Date _____________

Make check payable to: _______

______________________________

Reason for hand check: _______

______________________________

Hours ____________._____

Rate ____________._____

Gross Wage ____________._____

Federal ____________._____

State ____________._____

FICA ____________._____

Local ____________._____

Medicare Tax ____________._____

___________ ____________._____

Paycheck $____________._____

Requested by ____________________

Authorized by ____________________