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This form is to be used for all pay deduction complaints. Any employee who believes the district has made an inappropriate deduction is encouraged to immediately consult with their direct supervisor. The employee may also file this complaint form with the Chief Human Resources Officer explaining the nature of the improper deduction.
Name of employee: ______________________________________________
Department/Building: _____________________________________________
Payroll date(s): __________________________________________________
Amount of improper pay deduction: __________________________________
Explanation of improper pay deduction: ______________________________________________________________________
______________________________________________________________________
Supervisor Signature: __________________________________ Date: _______________________________
Employee Signature: __________________________________ Date: ________________________________
Return the signed form to:
Linn-Mar Community School District
Human Resources Office
3556 Winslow Road
Marion IA 52302
Reviewed: 9/14; 8/17; 6/20; 4/23
Revised: 8/24
Related Policy: 403.27; 403.27-R