"Payroll Change Form - East Central Independent School District" - Texas

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Download "Payroll Change Form - East Central Independent School District" - Texas

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EAST CENTRAL INDEPENDENT SCHOOL DISTRICT
Payroll Change Form
Name___________________________________
Campus__________________________
Social Security # __________________________
Date____________________________
NAME & ADDRESS CHANGES
New Name___________________________________________________________________
New Address_________________________________________________________________
(Street)
(City, State, Zip)
Home Phone (____)___________________Cell Phone (____)__________________________
Area Code
Area Code
INSURANCE COVERAGE/HEALTH SAVINGS ACCOUNT CHANGES
Name of Insurance/HSA__________ _________________________ ___________________
Effective Date of Change______________________________________________________
Change Required_____________________________________________________________
(For example: delete, add, etc.)
Reason for Change____________________________________________________________
Health Savings Deduction Amount ______________________ ________________________
MISCELLANEOUS CHANGES
Delete Firstmark Credit Union Deduction Effective: _________________________________
Cancel Direct Deposit: Bank___________________________________________________
Effective Date____________________________________________
(To add direct deposit, Complete a Direct Deposit of Payroll Authorization Agreement)
Other Changes________________________________________________________________
____________________________________________________________________________
____________________________
Ins. Chg Initialed: ________EF_________
Employee Signature
Payroll Office Use:___________________
*Changes need to be submitted prior to Close-Out Dates.
8/14/12 Checklist: ____ Reg XX ____Excel Change List ____Trans ____I-9 ____File Folder ____Aesop ____TCP ____Salary Spreadsheet
EAST CENTRAL INDEPENDENT SCHOOL DISTRICT
Payroll Change Form
Name___________________________________
Campus__________________________
Social Security # __________________________
Date____________________________
NAME & ADDRESS CHANGES
New Name___________________________________________________________________
New Address_________________________________________________________________
(Street)
(City, State, Zip)
Home Phone (____)___________________Cell Phone (____)__________________________
Area Code
Area Code
INSURANCE COVERAGE/HEALTH SAVINGS ACCOUNT CHANGES
Name of Insurance/HSA__________ _________________________ ___________________
Effective Date of Change______________________________________________________
Change Required_____________________________________________________________
(For example: delete, add, etc.)
Reason for Change____________________________________________________________
Health Savings Deduction Amount ______________________ ________________________
MISCELLANEOUS CHANGES
Delete Firstmark Credit Union Deduction Effective: _________________________________
Cancel Direct Deposit: Bank___________________________________________________
Effective Date____________________________________________
(To add direct deposit, Complete a Direct Deposit of Payroll Authorization Agreement)
Other Changes________________________________________________________________
____________________________________________________________________________
____________________________
Ins. Chg Initialed: ________EF_________
Employee Signature
Payroll Office Use:___________________
*Changes need to be submitted prior to Close-Out Dates.
8/14/12 Checklist: ____ Reg XX ____Excel Change List ____Trans ____I-9 ____File Folder ____Aesop ____TCP ____Salary Spreadsheet