Employee Pay Stub Request

EMPLOYEE PAY STUB REQUEST

Personal Information

Employee Name:

Employment / Position Information

Reporting Manager:

Employment Start Date:    Current Employee ID:

Pay Stub Request Details

Request Type:

Pay Period Start:    Pay Period End:

Number of Pay Stubs Requested:    Preferred Language:

Email    U.S. Mail    In-Person Pickup    Secure Employee Portal

Authorized Third-Party Release

Do you authorize release to a third party?    Yes    No

Employment History (for verification)

Employer 1

Title / Role:    From:    To:

Employer 2

Title / Role:    From:    To:

Education

Graduation Date:

Professional References

Reference 1

Reference 2

Reference 3

Privacy, Authorization and Certifications

By signing this form I certify that the information provided on this request is true, accurate and complete to the best of my knowledge. I authorize the employer and designated payroll agent to locate and release the requested pay stub records to me or my authorized designee as indicated above.

I understand that identification and identity verification may be required prior to release of any payroll information. I further acknowledge that there may be processing fees or a reasonable processing period; the employer will notify me of any such fees and the expected timeline prior to release.

I authorize the employer to contact prior employers or payroll providers for the purpose of verifying information related to this request if necessary. I also acknowledge that this authorization is limited to verification of employment and payroll records and does not authorize broad background investigations beyond the scope necessary to fulfill this request.

At-Will Employment: Nothing in this form alters the at-will employment relationship between the employee and employer, where applicable, except by a separate written agreement signed by authorized representatives.

Equal Employment Opportunity Statement: The employer provides equal employment opportunity and does not discriminate in handling employee requests based on protected characteristics.

Acknowledgement and Signature

By signing below I certify under penalty of perjury that I am the individual named above (or the authorized representative listed) and that I have the authority to request and receive the pay stub records specified. I understand that false statements or attempts to obtain pay records through misrepresentation may result in disciplinary action.

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