Personal Information

Surname / First Name (Legal name) / Middle Name 1 / Preferred Name (If different from first)

Job Information

Empl ID

/

NEW #

/

ER

/

BR

/ Previous Incumbent in Job
Effective Dt (m/d/y) /

Planned End Date ( term Jobs)

Action / HIRE / REHIRE / TRANSFER /
PROMOTION / RECALL / RTN: LEAVE DISAB / EARN DIST
PAYCHANGE / DATA CHG / OTHER
Reason
(Select one) / - Hire (HIR)Rehire (REH) /

- Promotion(PRO)Job Reclass (JRC)Job Regrade (JRG)

/ - SeasLayoff(SEA)Suspensn (SUS) / - Full Return (RFL/RFD)Grad Rtn Disab (GRD)Partial Rtn Lv (PRL)
Other: / - Account Change (ERD)Pay Chg-FTE/Std Hrs (FTE)Pay Chg-Reg Inc Step(SPG)Pay Chg-Incrmnt NoStep(INC)Pay Chg - Adjustment (ADJ)Pay Chg - Part Leave (PLV)Pay Chg - Part Rtn Lv (FTP)Pay Chg - Full Rtn Lv (FLL)Pay Chg - Part Disab (PLD)Pay Chg-Grad Rtn Dis(FTD)Pay Chg - Full Rtn DisabPay Chg - Merit (MER)Pay Chg - Other
Other: / - Extend End Dt (EXT)Benefits (BEN)Other
Other: / - Additional PayOne Time PaymtOther Change
Other:
Company / Business Unit / Incumbent Status/ Job Status
PMT / - PMTOS - Paymaster Out of ScopePMTIN - Paymaster In Scope / - PERMANENTSEASONALTERM

Dept ID

/ Dept Name / Benefit Pkg / None Yes: see below
Job Code /

Job Title

Std Hrs/Wk(Actual) /

Max Hrs/ Wk

/

35.00 36.00 36.25

37.50 38.00 40.00

/

FTE (std/max)

/

Work Schedule: Specify:(i.e. M-F, MWF)

Pay Group / MNP /

Monthly Rate

(1.0 FTE)

/

Prorated Monthly Rate

(IfFTE<1.0)

/ If Change,
Old Rate

Job Earnings Distribution

/ If Change: OLD Account
C / Fund (6) / Orgn (4) / Acct(5) / Prg (4) / Acty(5) / Percent / Earn / C / Fund (6) / Orgn (4) / Acct(5) / Prg (4) / Acty(5) / Percent
2 / - 60203 60204 / 100 / 2 / - 60203 60204
2 / - 60203 60204 / 100 / 2 / - 60203 60204

Ongoing Additional Pay (Type: stipends, supplements, differentials, etc… Enter End Date if known).

Earnings Type / Earn / Effective Dt / Sq / End Date / Actual / Month / Reason etc. / C / Fund (6) / Orgn (4) / Acct (5) / Prg (4) / Acty(5)
2 / - 60203 60204
2 / - 60203 60204

Benefits: YES - Univ/Non Univ – Select plans if eligible. Contact the Benefit Office for more information. Note: Dental & Life plans have a 3 month waiting period.

10 Ext Health / - OPEHF1: Family - Er paidOPEHF2: Family - Shared costOPEHS1: Single - Er paid / 11 Dental / - OPDNF1: Family - Er paidOPDNF2: Family - Shared costOPDNS1: Single - Er paid / 20 Life / - BASGLF (3x-Max40000))
80 Pension / - MPRCHA - 5 %MPRCHB - 6.82%MPRCHC - CEPMPRCHD - IATSEOther, specify If Other: / 8Z Disability / - SALCNB - 1.8 %SALCNC - 1.88 %

Remarks / One Time Payments (Note: To report OT, Extra Hours and other One Time Payments for hours worked, use the Hourly Payments JIF).

Authorization:

DatePrepared by / For Information Contact (Please print)PhoneAuthorized Signature *DO NOT USE BLACK INK*

Do not write below this line

Payroll
Dt Processed /

Processed By

/ Authorized By / Pay Dt

Revised 02/01/2005