Santa Rita Union School District
Payroll Department Inquiry Form

Name:         Date:

School Site:                         Phone # or Extension:

If you have questions or concerns regarding any of the following, please check the appropriate box and give a brief description.

My medical card has not arrived. When can I expect to receive it?

I have questions regarding my medical plan.

I would like to increase or decrease my benefit plan.

I would like to sign up for automatic deposit for my paycheck. Please send me the appropriate form.
       (Please remember that it will not go into effect for 2 months)

I would like to change the status of my State and/or Federal Tax withholdings. 
      Please send me the appropriate forms.

Other

Explanation of Inquiry:

I have a problem with my paycheck. Please forward a copy of the Paycheck Stub and explain.

All inquiries will be forwarded to Kim Carlson. You may print this form if you wish or call 443-7200 ext. 280
(Please allow for a minimum of 5 days for your request to be processed.)