2. Prior Period Adjustment form
4. First Name*
5. Last Name*
7. Department*
   -- Select One --AdministrationEngineering, Planning & Economic DevelopmentFinanceInformation TechnologyHuman ResourcesParks & RecreationPolice DepartmentPW - AdminPW - MaintenancePW - WastewaterPW - Water
9. Date(s) to be adjusted:
11. Date(s) of adjustment:*
    Date(s) of adjustment:
12. Date(s) of adjustment:
    Date(s) of adjustment:
13. Date(s) of adjustment:
    Date(s) of adjustment:
15. # of Hours *
16. # of Hours:
17. # of Hours:
19. Detailed description of adjustment(s):
21. Required for all prior period adjustment requests:*
Leave This Blank:


23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit Submit and Print

* indicates a required field