SHARP EMPLOYEE DATA SHEET

EMAIL OF PERSON SUBMITTING REQUEST

TELEPHONE NUMBER OF PERSON SUBMITTING REQUEST

FEDERAL TAX DATA

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 FED TAX GROSS

EARNED INCOME CREDIT

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

ACTION  Add   Change           EFFECTIVE DATE

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  

(Note: Leave blank if exempt).

ACTION  Add    Change

DEDUCTION CODE    EFFECTIVE DATE  

DEDUCTION END DATE

ACTION  Add    Change

DEDUCTION CODE   EFFECTIVE DATE  

RETIREMENT PLANS

PLAN TYPE       KPERS   TSA

DEDUCTION BEGIN DATES   

PARTICIPATION ELECTION       Elect   Waive   Terminate

BENEFIT PLAN    ELECTION DATE    

DEDUCTION END DATES 

UNITED WAY:(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

AGENCY MAINTENANCE: (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 DeductionCalc.Routine=FlatAmount

DEPENDENT/BENEFICIARY INFORMATION:

ACTION      Add New   Change Data

NAME  (Last, First, MI)

ADDRESS 1                     ADDRESS 2

CITY         STATE       ZIP

RELATIONSHIP      SEX  Male   Female            

SSN

ACTION   Add New   Change Data

NAME   (Last, First, MI)

ADDRESS 1                          ADDRESS 2

CITY              STATE   ZIP  

RELATIONSHIP          SEX  Male   Female       

SSN

BOND SPECIFICATIONS:

EFFECTIVE DATE PRIORITY

DENOMINATION  $100   $200   $500   $1,000   $5,000   $10,000

BOND OWNER:

OWNER NAME           EMPLOYEE OR DEPENDENT   

CO-OWNER NAME        EMPLOYEE OR DEPENDENT  

OTHER REGISTRANT   None    Co-owner    Beneficiary

CO-OWNER OR BENEFICIARY
NAME     EMPLOYEE    OR DEPENDENT  

PORTION OF DEDUCTED AMOUNT:

FLAT AMOUNT OR PERCENT OF DEDUCTION   

EXCESS    PARTIAL ALLOWED

ACTION  Add   Change    Cancel   

DEDUCTION BEGIN DATE DEDUCTION END DATE

BENEFIT PLAN

BEFORE TAX INVESTMENT: FLAT AMOUNT Amount   

PERCENT OF DEDUCTION Percent  

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

CHARGE ADDITIONAL PAY TO:

DEPARTMENT   JOB CODE   POSITION NO.

GL PAY TYPE     POSITION POOL ID

CHECK ADDRESS:

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

COUNTRY