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CAREGIVER TIME SHEET

2010 Payroll: # ____ Dates for Pay Period: _____/_____ to _____/_____ Caregiver ________________________________

Client ________________________________

Due Dates: Time sheets are due every other Saturday (last day of each pay period). Paychecks will be distributed the following Thursday. S b t i s e t b t ed ed t. f o r i s e t a elt, o wo 'rc ieap y h c u t t efl wigp yol u mit me h es y h u ae I y u t me h es r ae y u nt e ev a c e k n i h ol n a r l l o . Fax to 503-251-9854. Drop off at 4804 NE 106th Avenue, Portland, OR 97220-2503. If mailing, allow enough delivery time. 1) Complete information above. 2) Write in dates and times worked. 3) Write in daily totals. 4) Write in total hours for pay period. 5) Sign time sheet. Day of Week Date Time In Time Out Time In Time Out Daily Total

For these shifts, only check box on start date. 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr 12-hr 24-hr

Sun

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Mon

Tue

Wed

Thu

Fri

Sat

For office use only: Brief Weekday Weekend 12-hour 24-hour Holiday Payroll Total

Total

Total Hours for Pay Period: _________

I certify that the information documented on this time sheet is true and accurate.

Notes:

Caregiver Signature: _____________________________

2010 Payrolls: #1 12/27/09-1/9/10 (check date 1/14/10) #2 1/10-1/23 #3 1/24-2/6 #4 2/7-2/20 #5 2/21-3/6 #6 3/7-3/20 #7 3/21-4/3 #8 4/4-4/17 #9 4/18-5/1 #10 5/2-5/15 #11 5/16-5/29 #12 5/30-6/12 #13 6/13-6/26 #14 6/27-7/10 #15 7/11-7/24 #16 7/25-8/7 #17 8/8-8/21 #18 8/22-9/4 #19 9/5-9/18 #20 9/19-10/2 #21 10/3-10/16 #22 10/17-10/30 #23 10/31-11/13 #24 11/14-11/27 #25 11/28-12/11 #26 12/12-12/25 (check date 12/30/10)

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