Payroll/Benefits Transaction Form (DOT-129)
DOT-129 WEST 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 |$ | |
| | 642 Fairmont City User Fee |$ 4.33 | |
| | Start Stop | | |
| | 643 Parkersburg City User Fee |$ 5.42 | |
| | Start Stop | | |
| | | |
| | 683 Workers’ Comp Buyback | | |
|* | 684 Retirement Buyback | | |
| | 695 Huntington City User Fee |$ |6.50 | |
| Start Stop | | |
| | 698 Charleston City User Fee |$ |4.33 | |
| | Start Stop | | |
|* | Union Dues |$ | | |
| | AFSCME (860) UE17 (894) | |
| | | |
|III SEPARATION 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 | | |
| | | | |
|IV OTHER: | | |
| | Sick Leave Recredited | | |
|* | Leave Transferred: Ann. | |Sick | | |
| | Employee Birth Date | | |
|* | Prior State Service | | |
| | Military Service | | |
| | LOA |Months | |Days | | |
| | Other | | |
V HUMAN 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) |$ | | |100 |
| | | |Dep| |
| | | |end| |
| | | |ent| |
| | | |Lif| |
| | | |e | |
| | | |Pla| |
| | | |n | |
| | | |Dep| |
| | | |end| |
| | | |ant| |
| 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 | |Employee Signature |
|Note: This signature is not required for changes made exclusively to | | |
|shaded areas. | | |
| | | |
| | |Prepared by |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- 129 ford fusion lease deal
- payroll benefits administrator job description
- payroll benefits specialist job description
- payroll benefits administrator
- payroll benefits administrator job duties
- payroll tax filing form 941
- payroll authorization deduction form template
- wisconsin dot form mv 2488
- payroll deduction authorization form pdf
- dot physical form pdf 2021
- dot physical form 2021
- dot physical form 2020