NAME OF PERSON SUBMITTING REQUEST: 

Last Name:     First Name:

EMAIL OF PERSON SUBMITTING REQUEST: 

TELEPHONE NUMBER OF PERSON SUBMITTING REQUEST: 

ACTION:     Add Change     EFFECTIVE DATE: 

SPECIAL TAX STATUS:      None Maintain taxable gross

*FWT will be zero unless specified on additional withholding (exempt)

TAX MARITAL STATUS:     Single Married

WITHHOLDING ALLOWANCES:

ADDITIONAL WITHHOLDINGS:   Amount or % of fedtax gross

Not Applicable Single, or Married without spouse filing   Married with both spouses filing

STATE:       RESIDENT    NON RESIDENCY STATEMENT FILED     UI JURISDICTION

SPECIAL TAX STATUS:   None Maintain taxable gross

*SWT will be zero unless specified on additional withholding (exempt)         

SWT MARITAL TAX STATUS:    Single Married

WITHHOLDING ALLOWANCES:

ADDITIONAL WITHHOLDINGS:   Amount or % of state tax gross

EXEMPT FROM SUT?

 LOCALITY:   LOCAL WITHHOLDING ALLOWANCES:

RESIDENT?

 GROUP TERM LIFE/LONG TERM DISABILITY INSURANCE

ACTION:       Add   Change

DEDUCTION CODE:   EFFECTIVE DATE:    DEDUCTION END DATE: 

 ACTION:  Add    Change

DEDUCTION CODE:   EFFECTIVE DATE:  

OTHER GENERAL DEDUCTIONS

  DEDUCTION CALC ROUTINE:

ACTION:  Add    Change     DEDUCTION END DATE:

DEDUCTION CODE:   EFFECTIVE DATE:      FLAT/ADDL AMT:

ACTION:  Add    Change

DEDUCTION CODE:    EFFECTIVE DATE:   

DEDUCTION END DATE:  

PLAN TYPE:  KPERS   TSA

DEDUCTION BEGIN DATES:    

PARTICIPATION ELECTION:  Elect   Waive   Terminate

BENEFIT PLAN:    ELECTION DATE:    

DEDUCTION END DATES:    

*(Deduction Calc. Routine = Flat Amount)

ACTION:    Add    Change

DEDUCTION CODE:   EFFECTIVE DATE:   DEDUCTION END DATE: 

FLAT/ADDL AMOUNT:   GOAL AMOUNT:

 ACTION:   Add    Change

DEDUCTION CODE:    EFFECTIVE DATE:   DEDUCTION END DATE: 

*(Deduction Calc. Routine = Flat Amount)

ACTION:  Add    Change

DEDUCTION CODE:    EFFECTIVE DATE:   DEDUCTION END DATE: 

FLAT/ADDL AMOUNT: 

Note: If requesting multiple bonds, a separate page will need to be completed for each bond.

ACTION:  Add Deduction   Change Deduction Amount   Cancel Deduction   

EFFECTIVE DATE:   

DEDUCTION CODE:   DEDUCTION END DATE:    

FLAT/ADDL AMOUNT:

ACTION:  Add   Change Cancel   

DEDUCTION BEGIN DATE: DEDUCTION END DATE:  

BENEFIT PLAN: 

BEFORE TAX INVESTMENT: Flat Amount    Percent of Deduction  

 ACTION:  Add   Change     EFFECTIVE DATE:   EARNINGS CODE: 

OVERRIDES TO JOB DATA:

ADDL SEQ NO.:    HOURS:    HOURLY RATE:     EARNINGS:    

REASON:

EARNINGS END DATE:   GOAL AMOUNT:

APPLIES TO PAY PERIODS:    First Second Third

DEPARTMENT:     JOB CODE:               POSITION NO.:

GL PAY TYPE:       POSITION POOL ID:

 Mail to Home Address      Mail to Mailing Address      Mail to Check Address

CHECK ADDRESS:

ADDRESS 1:

ADDRESS 2:

CITY:                 

STATE:      ZIP:     COUNTRY: