Time Sheet and Billing Form

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District Financial Aid Office
11011 SW 104 Street, Room 1125, Miami, FL 33176
Florida Work Experience Program: (305) 237-0243
Facsimile: (305) 237-2787

Time Sheet and Billing Form

Please fill out this form completely and accurately.
SCAN AND EMAIL a signed time sheet to workprogram@mdc.edu WITH YOUR PAYROLL DOCUMENTATION FOR THE MONTH NO LATER THAN THE 15th DAY OF THE NEXT MONTH.

Name of Firm:

Tax Payer Identification Number:

Telephone Number:

Student's Name:

SSN:(only the last 4 digits)

MDConnect Student ID Number:

Pay Period:

From: MM/DD/YYYY

To: MM/DD/YYYY

Hours Worked by Calendar Day

SUN

MON

TUE

WED

THU

FRI

SAT

Total Hours Worked

Week 1

Week 2

Week 3

Week 4

Week 5

Total Hrs. Worked:

Hourly Rate of Pay:

Gross Compensation:

I hereby certify that this Time Sheet is a true statement of the time worked by me and that I have been paid by the employer for the amount shown.

Student's Signature:  ___________________________________________       Date:  _____________________

I hereby certify that this Time Sheet is a true statement of the time worked by this student, that the work assigned was completed satisfactorily and that the student has been paid the amount of net earnings as shown.

Employer's Name:  ___________________________________

Employer's Signature:__________________________________     Date:  _____________________

Received By:  ________________________________________     Date:  _____________________

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