(CHECK HERE) "I (the staff person named below) CONFIRM under the penalties of perjury that I have provided the information below and that it is truthful and accurate to the best of my knowledge and belief.

By submitting this document, I CONFIRM my AGREEMENT TO and COMPLIANCE WITH all terms and conditions in the FORM-SP1, the "EXPERIENCING IMAGINATION STAFF POLICY".

Complete the following: 

(YOUR SUBMISSION WILL BE REJECTED WITHOUT THIS INFORMATION AND DELAY ANY PAYMENTS DUE.)

LAST 4 DIGITS OF
SOCIAL SECURITY #:

 SUPERVISORS FIRST AND LAST NAME:

ON THE LINES BELOW INDICATE THE TOTAL NUMBER OF HOURS ACTUALLY WORKED (INCLUDING THE 30 MINUTES PER 4 HOURS PERSONAL TIME FOR BREAKS & MEALS).

SELECT "SERVICES" IN THE CORRECT DROP DOWN BOX FOR EACH LINE YOU ARE CLAIMING SERVICE HOURS (HOURS WORKED).

ENTER "0" HOURS WORKED IF VACATION, PERSONAL TIME OR APPROVED COMP TIME (SEE YOUR SERVICE HOURS SUMMARY LOG) IS BEING USED, THEN SELECT THE CORRECT DROP DOWN BOX CATEGORY (COMP TIME, PERSONAL TIME, VACATION TIME) WHERE HOURS ARE TO COME FROM. IF NOT ENOUGH HOURS ARE AVAILABLE, THE NEXT AVAILABLE CATEGORY WILL BE USED (IF STILL NOT ENOUGH HOURS AVAILABLE, TIME WILL BE UNPAID)

--YOUR SUBMISSION WILL BE SENT TO YOUR SUPERVISOR FOR APPROVAL--

COMPLETE THE FOLLOWING FOR THE PAYROLL PERIOD INVOLVED:

16TH

PLEASE DATE, SIGN AND PRINT A HARD COPY OF THIS FORM BEFORE SENDING INFORMATION.

GIVE THE HARD COPY TO YOUR SUPERVISOR