W. Va. Code R. agency 158, tit. 158, ser. 158-14, app A
THIS FORM AND THE CORRESPONDING VERIFIED TIME RECORDS ONLY HAVE TO BE FILED IF DURING THE QUARTERLY REPORTING PERIOD THE PUBLIC EMPLOYEE MISSED TIME TO PERFORM THE WORK DUTIES OF ANOTHER PUBLIC OFFICE OR EMPLOYMENT AND WAS AUTHORIZED TO MAKE UP TIME. THE TIME RECORDS MUST BE SUBMITTED FOR THE ACTUAL WORK DAYS OR PAY PERIODS DURING WHICH THE TIME WAS EITHER MISSED OR MADE UP. IF THE TIME IS MADE UP IN ANOTHER REPORTING PERIOD, THEN THE PUBLIC EMPLOYEE IS REQUIRED TO SUBMIT THIS FORM AND CORRESPONDING TIME RECORDS DURING THAT REPORTING PERIOD AS WELL.
NAME OF PUBLIC EMPLOYEE:
JOB TITLE OF PUBLIC EMPLOYEE:
CHECK THE BOX TO INDICATE IF THE EMPLOYEE IS PART-TIME OR FULL-TIME.
PART-TIME:
FULL-TIME:
PUBLIC EMPLOYER:
NAME:
MAILING ADDRESS:
TELEPHONE NUMBER:
PUBLIC EMPLOYEE'S IMMEDIATE SUPERVISOR:
JOB TITLE OF IMMEDIATE SUPERVISOR:
CHECK A BOX TO INDICATE THE DESIGNATED PAY PERIOD FOR THE PUBLIC EMPLOYEE:
WEEKLY:
EVERY TWO WEEKS:
TWICE A MONTH:
OTHER:
IF OTHER, INDICATE IN THE SPACE PROVIDED THE DESIGNATED PAY PERIOD:
LIST THE OTHER PUBLIC OFFICE OR EMPLOYMENT HELD BY EMPLOYEE. INCLUDE THE ADDRESS AND TELEPHONE NUMBER:
CHECK A BOX TO INDICATE WHETHER THE OTHER PUBLIC OFFICE OR EMPLOYMENT IS A PART-TIME OR FULL-TIME POSITION.
PART-TIME:
FULL-TIME:
CHECK QUARTER FOR WHICH THE FORM IS BEING FILED:
January 1st - March 31st
April 1st - June 30th
July 1st - September 30th
October 1st - December 31st
I,___________________, IN ACCORDANCE WITH WEST VIRGINIA CODE § 6B-2-5(k), VERIFY THAT THE TIME RECORDS SUBMITTED SHOW THE HOURS THAT I DID IN FACT WORK FOR THIS PUBLIC EMPLOYER.
EMPLOYEE SIGNATURE DATE
I,___________________, IN ACCORDANCE WITH WEST VIRGINIA CODE § 6B-2-5(k) VERIFY THAT I AM THE IMMEDIATE SUPERVISOR OF THIS EMPLOYEE AND THAT, TO THE BEST OF MY KNOWLEDGE, THE TIME RECORDS SUBMITTED SHOW THE HOURS THAT THE EMPLOYEE DID IN FACT WORK.
IMMEDIATE SUPERVISOR SIGNATURE DATE
W. Va. Code R. agency 158, tit. 158, ser. 158-14, app A