IC DISCREPANCY (ADJUSTMENT) FORM Discrepancies MUST be submitted within 30 Days of the POD completion date to be reviewed. Discrepancies submitted after will not be considered. IC Settlement Discrepancy Form Date Submitted: * IC (Vendor) #: * IC Name: * IC Name: First First Last Last IC Phone number: * IC Email: * Order #: * Date of Services: * Commission Listed: * Commission Expected: * Brief description of discrepancy: Manager or Dispatcher’s name who confirmed the Expected Commission: Manager or Dispatcher’s name who confirmed the Expected Commission: First First Last Last To be completed by SLL staff: Select one: Commission ApprovedCommission Declined Date Reason for Decline: (If Applicable) Reviewer Date Submit If you are human, leave this field blank.
