EMPLOYEE PAYROLL & BENEFITS
PAYROLL FORMS

Note: To view and print the forms in PDF Files, Adobe Acrobat Reader  5.0 or higher is required. It can be downloaded free from Adobe Website .

Absence Forms

These forms may downloaded from your computer. You complete them and turn them in to your supervisor (Director, Dean, Vice-President, Supt./Pres).

Classified Bargaining Unit Academic Bargaining Unit Management Associate Faculty

Address/Name/Retirement Change Form (Employee Information Sheet)
This form may be completed and sent online to Human Resources. (PIN required) It also may be downloaded, then completed, and sent to Human Resources.

Authorization to Release Paycheck
This form may be downloaded, completed, and delivered, mailed, or faxed to the payroll office. (PIN required)

Deferred Net Pay (10-pay over 12-months)

Employee Electronic Deposit Form (EFT)

This 2-page form can be downloaded. Complete both pages in full, attach a voided check or bank document showing your 9-digit banking transit number and your complete account number and send it to the Payroll office. (PIN required)

 Tax Withholding forms

Alll these forms may be downloaded as a PDF file, completed & sent or delivered to Payroll. 
W-4, W-5, DE4 changes will take effect the next available payroll following receipt in the payroll office.

W-4 (Federal Withholding) W-5 (Federal Earned Income Credit) DE4 (California Withholding Certificate) W-2 Request for Duplicate (PIN Required)

Tax Shelter Annuities (TSA) information & forms

(Generally eligible if regularly working 20 hrs or more weekly)

TSA Provider List  and Voluntary Salary Reduction Agreement Form (VSRA)   TSA Providers: San Bernardino County Superintendent of Schools: Business Advisory Services - 403b Third Party Administration

BENEFITS FORMS

Unless there is a Qualifying Event, typically, you may make no medical/dental/vision/IRC 125 changes other than during Open Enrollment.  Dial Ext. 2252 for information.  You may also refer to the Benefits Information area in this website.

Beneficiary changes:  (PIN required for all forms except STRS and PERS)

Standard Life Prudential Life (formerly Transamerica) Prudential Accidental Death (formerly Transamerica) STRS  (State Teachers’ Retirement System (One-Time Death Benefit Recipient) PERS  (Public Employee Retirement System)

Enrollment changes: (PIN required for all forms)
 

Qualifying Event Notice (required for all changes other than during Open Enrollment) Delta Dental DPO Delta Dental PMI Eyemed Vision Health Net Kaiser Permanente Safeguard Dental

Other: 

Domestic Partner Registry CalSTRS Permissive Election Form (Associate Faculty) – contact Payroll CalSTRS Address Change Other CalSTRS forms CalPERS Address Change (click under Shortcuts) Other CalPERS forms (click under Shortcuts)

 IRC Section 125 Forms:  (Pin required)

American Fidelity Medical and Dependent Care Reimbursement Accounts – administered through American Fidelity

Note: To view and print the forms in PDF Files, Adobe Acrobat Reader  5.0 or higher is required. It can be downloaded free from Adobe Website .

Last Modified: 2008-03-31 .