Employee Data Sheet - Part B | Kansas Department of Administration

Last Name:

First Name:

Email of Person Submitting Request:

*

Telephone Number of Person Submitting Request:

Dept. ID:

Empl. ID:

Empl. Name:

Empl. Rcd. Nbr.:

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:

Action:

Add

Change

Deduction Code:

Effective Date:

Deduction End Date:

Flat/Addl Amount:

Action:

Add

Change

Deduction Code:

Effective Date:

Action:

Add

Change

Deduction Code:

Effective Date:

Deduction End Date:

Action:

Add

Change

Deduction Code:

Effective Date:

Plan Type:

KPERS

TSA

Deduction Begin Dates:

Participation Election:

Elect

Waive

Terminate

Benefit Plan:

Election Date:

Deduction End Dates:

Action:

Add

Change

Deduction Code:

Effective Date:

Deduction End Date:

Action:

Add

Change

Cancel

Deduction Begin Date:

Deduction End Date:

Benefit Plan:

Before Tax Investment: Flat Amt:

Percent of Deduction:

Action:

Add

Change

Effective Date:

Earnings Code:

Attl 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:

Consent Confirmation:

*

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Employee Data Sheet - Part B

United Way

KPERS

Group Term Life/Long Term Disability Insurance

Overrides to Job Data

Charge Additional Pay To

Please remember to fill out the EMPLID, DEPTID and Name at the top of this form