VALDOSTA STATE UNIVERSITY EXTRA/DUAL COMPENSATION FORM
CHECK ONE
:
Student Employee
BI-Weekly Paid Employee
Monthly Paid Employee
NAME OF PAYEE:
Last:
First:
MI:
SSN (Last 4 Digits):
DEPARTMENT WORKED FOR:
EXPLANATION OF DUTIES:
DATE(S) SERVICE RENDERED:
HOURS WORKED:
FROM
TO
- TOTAL HOURS
RATE OF PAY PER HOUR OR PER SERVICE:
This agreement meets the requirements set out on page 134-135 of the Policies of the Board of Regents. University System of Georgia which are as follows: 1) The work is carried in addition to a normal full load. 2) No qualified person is available to carry to work as part of his/her normal load. 3) The work produces sufficient income to be self-supporting. 4) The additional duties must not be so heavy as to interfere with the performance of regular duties. It is specified that the extra compensation will be paid as a supplement payroll item by the 10th day of the following month, deducting FICA. Federal and State taxes, with the understanding that the total compensation paid during the calendar year will be reported as taxable income on a W-2 form to the Internal Revenue Service.
AGREED TO BY:
Signature of Employee:
Date:
Title/Rank
Department
APPROVED BY:
Department Head/Dean/Director:
Department:
Date:
FOR MONTHLY PAID EMPLOYEES ONLY, THIS VICE PRESIDENT LINE MUST BE SIGNED:
APPROVED BY:
Divisonal Vice President/Cabinet Level Officer:
Date:
ACCOUNT NUMBERS(S) TO BE CHARGED
AMOUNT
$
$