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.

Google Online Preview   Download