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["STATE OF ALABAMA"]
["COMPTROLLER'S OFFICE"]
["SALARY OVERPAYMENT REFUNDS"]
[]
["Email signed form to Payroll at Comptroller--Payroll@Comptroller.Alabama.gov."]
["This form must be signed by an authorized departmental representative."]
[]
["This is a fillable form and will compute net pay and ITI totals."]
["PLEASE REFER TO FISCAL POLICY & PROCEDURES MANUAL PAGES 7-24 AND 7-25, SECTION C, FOR INSTRUCTIONS."]
[]
["*INVOICE # (ITI Doc ID):",null," ",null,"*CASH RECEIPT #:"," "]
[null,null,"(Required)",null,null,"(Required)"]
[]
["Agency Name:",null,null,null,null,"Agency Code:"]
[]
["Employee Name:",null,null,null,null,"Employee ID (10 digits):",0]
[]
["Balance Sheet Account #:",null,9050,null,null,"Warrant Amount",0]
[]
["Gross Amount:",null,null,null,null,"Warrant Date:","00:00:00"]
[]
["Check if Prior Calendar Year ",null,null,false,null,"Warrant Number:"]
[]
["Contact Comptroller Payroll for detailed instructions if prior year."]
[]
["Employee Share:",null,null,null,"  Employer Share:"]
["FICA   #1: ",null,{"$f":"ROUND((C20)*6.2%,2)","v":0},null," FICA  #1:",{"$f":"ROUND((C20)*6.2%,2)","v":0}]
[]
["Medicare  #1:",null,{"$f":"ROUND((C20)*1.45%,2)","v":0},null,"Medicare  #1 :",{"$f":"ROUND((C20)*1.45%,2)","v":0}]
[]
["Federal Withheld  #1:",null,0]
[null,null,null,null,"Retirement  #1:",0,0]
["State Withheld  #1: ",null,0,null,"Enter employer retirement ONLY if employee has not been refunded employee share at Retirement Systems Alabama."]
[]
["City Occupational Tax   #1",null,0]
["City Tax Code ",null,null,null,null,"Invoice ITI AMOUNT :",{"$f":"C27+C29+C31+C33+C35+C38+C41+F27+F29+F32","v":0}]
[null,null,0,null,"This is the amount that will be transferred to your agency through an ITA.  It should be the sum of all items marked with a #1."]
["County Occupational Tax #1"]
["County Tax Code"]
[]
["Retirement  #1:","Retirement #1:",null,null,"REASON FOR REFUND (REQUIRED)"]
["Enter amount above ONLY if funds are still held in employee's account at Retirement Systems Alabama and agency will be requesting a refund. "]
[]
["Insurance  "]
["**Please note:  Insurance amounts included in this box   should be requested back through SEIB.**   "]
[]
["Other Deductions    "]
["Enter amount above ONLY if agency will be requesting a refund from the third party vendor."]
[]
[null,"Net Amount:",{"$f":"C20-C31-C27-C29-C33-C35-C38-C41","v":0},"(Cash Receipt Amt)"]
["**Please note:  Amount listed in the Insurance box is NOT included in the calculation of the net amount.**  "]
[]
["I confirm that the above warrant is being submitted for cancellation and information provided is true and correct."]
[]
["CONTACT PERSON:",null,null,"EMAIL:",null,null,"PHONE NUMBER:"]
[]
[]
[]
["Authorized Departmental Approval",null,null,null,null,"(Date)"]