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

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download