DOT-129WEST VIRGINIA DEPARTMENT OF TRANSPORTATION

(8/2011)Payroll/Benefits Transaction Form

Organization No. / Social Security No. / - - / EPICS Employee No.
Employee Name
Address

New Employee Status Change Section(s) Action I II III IV V

PAYROLL INFORMATION

If this form is being completed to change an item in this section only for an existing employee, submit to Payroll only.

*Requires additional form(s) and/or documentation

I PAY AND DEDUCTIONS INFORMATION:
Marital Status-Payroll Deduction Only
Married
Single
Salary Regular Employee
Civil Service Hourly Employee
Civil Service Salary Employee
Hourly Rate / $
Monthly Salary / $
Annual Salary / $
* / Fed. Exemptions
* / Federal Amount / $
State Tax Code
* / State Exemptions
* / State Amount / $
Employment Status
Full Time Employ / Perm / Reemp
Part Time Employ / Temp / RET LOA
Temp Employee / Coop
Date Begin Pay
II MISCELLANEOUS DEDUCTIONS:
* / 115 Vehicle Use
* / 320 ING Start Date
$ / Opt out
Supp. Ins. Deduction / $
642Fairmont City User Fee / $ 4.33
Start Stop
643 Parkersburg City User Fee / $ 5.42
Start Stop
683 Workers’ Comp Buyback
* / 684 Retirement Buyback
695 HuntingtonCity User Fee / $ / 6.50
Start Stop
698 CharlestonCity User Fee / $ / 4.33
Start Stop
* / Union Dues / $
AFSCME (860)UE17(894)

IIISEPARATION TYPE:

/
Date of Separation
Leave of Absence / From:
To:
Resignation
Retirement
Termination
Death
Last Day of Pay
Sick Leave Bal Last Day of Pay
Ann. Leave Bal Last Day of Pay

IVOTHER:

/
Sick Leave Recredited
* / Leave Transferred: Ann. / Sick
Employee Birth Date
* / PriorState Service
Military Service
LOA / Months / Days
Other

VHUMAN RESOURCES BENEFITS INFORMATION

If this form is being completed to change an item in this section only for an existing employee, submit to Human Resources only.

Health Ins Plan Code / 615 Optional Life Ins (Non-Tax Shelter) / $
380 Health Ins (Tax Shelter) / $ / Dependent Life Plan Dependant / 100 / 200 / 300 / 400
608 Health Ins (Non-Tax Shelter) / $ / 617 Dependent Life / LDO1 / $
$
Tobacco-free Tobacco-user / 384 Mt Flexible Benefits / $
935 Basic Life InsLBO1 / $ / 385 Mt Flexible Dependent Care / $
Optional Plan CodeLOO1 / 686 Mt Flex Legal Plan / $
381 Opt Life Ins (Tax Shelter) / $

Overtime Code: No Overtime (9) Straight Time (5) Time and Half (2) Comp Time (1)

(No other changes should be requested on this form when changing the Overtime Code)

Effective Date:
REMARKS:
District Engineer/Manager or Division Director
Note: This signature is not required for changes made exclusively to shaded areas. / Employee Signature
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