TENNESSEE STATE UNIVERSITY
Part 2 of 2
TENNESSEE STATE UNIVERSITY
EMPLOYEE EXITING AND CLEARANCE REPORT
Name ___________________________________ T#______________ Position_________________________________
Dept ___________________________________________ Supervisor/Dept Head_________________________________
The following benefits and final compensation will be discussed with the employee and executed based upon established exiting policies, procedures and/or guidelines of TSU, the State of Tennessee and the Tennessee Board of Regents.
Type of Separation: ___ Voluntary ___Involuntary ___ Retirement
Effective Date: ______________________________
Last Day Worked: _______________________________
Final Paycheck: _______________________________
Annual Leave Payment Method: ___ Lump Sum ___ Extended ___ Transfer (State Agency/School System)
Sick Leave (non-payment): ___ Retirement Credit ___ Transfer (State Agency/School System)
Retirement Plan: ___ TCRS ___TIAA/CREF ___VALIC ___ AETNA
Application for Retirement Submitted or Requested: ____ Yes ____ No ____ N/A
Benefits: State of Tennessee
Health Insurance Continuation: ___ Yes ___ No ___ COBRA ___ N/A Reason: __________________________
Dental Insurance Continuation: ___ Yes ___ No ___ COBRA ___ N/A Reason: __________________________
Basic Term/Optional Life Insurance: ___ Yes (forms sent by company) ___ N/A
Deferred Compensation: ___401-K ___403-B ___457
Disability Plan- Conversion: ___ ITT Hartford LTD ___ TIAA LTD ___Yes ___No ___ N/A
Long Term Care- Conversion: ___Yes ___No ___ N/A
Direct Deposit: Final Paycheck (refer to direct deposit statement on form for separating employee)
Address Change: ____Yes ____No (Will contact HR if future address change)
Submitted: Parking Decal ____Yes ____No ____N/A (Retiree)
ID Cards (TSU/TBR) ____Yes ____No ____N/A (Retiree)
Resignation Letter ____Yes ____No
PARF Prepared (Dept) ____Yes ____No ____Pending Reason:__________________________
Reason for Separation (if voluntary): ________________________________________________________________________
Should HR share your statement/reason for separating with department/division head?: ___Yes ___No
I certify that the benefits elected by me have been verified and discussed with me to my satisfaction and in accordance with
information that I have provided, verbally or in writing, and the procedures HR adheres to in compliance with prescribed
policies and procedures.
Employee Signature: ___________________________________ Date: ____________________________________
HR Representative: ____________________________________ Copy To: ________________________________
Original: Human Resources Copy: Employee Personnel File
Rev: HR 01/05
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