Employment Change Request
Pay Rate Increase
Employee Name
*
Department
*
Please Select
Auditor
Building Maintenance
County Clerk
County Court at Law #1
County Court at Law #2
County Judge
District Attorney
District Clerk
Domestic Relations
DPS
Elections
Extension
Fire Department
HR/Payroll
Information Technology
Judicial Enforcement
Justice of the Peace #1
Justice of the Peace #4
Juvenile Probation
Maintenance
Managed Assigned Counsel
Mental Health
Purchasing
Road and Bridge
Sheriff Office
Tax Assessor/Collector
Treasurer
Youth Center of the High Plains
SO Department
Please Select
010-621 - Main
010-623 - Jail
010-624 - Medical
010-625 - Mechanic
010-626 - Net
010-627 - IT
031-600 - Courthouse Security
Effective Date
*
/
Month
/
Day
Year
Date
Pay Date
*
/
Month
/
Day
Year
Date
From Annual Salary
*
Bi-Weekly Salary
To Annual Salary
*
Bi-Weekly Salary
From Range
*
From %
*
To Range
*
To %
*
Is there a change in Fund or Department #: If Yes, then
Fund
Dept #
Uniform Allowance
Please Select
Not Applicable
$25.00 per month
$50.00 per month
$75.00 per month
Phone Allowance
Please Select
Not Applicable
$25.00 per month
$35.00 per month
(Please provide Court approval documentation)
Comments
Department Head Email Address
*
example@example.com
Completed By Email Address
*
example@example.com
Completed By Signature
Date
/
Month
/
Day
Year
Date
Department Head Approval
Date
/
Month
/
Day
Year
Date
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Submit
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