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Payroll Action Notice
Submitter's Information
Your Name
*
Your Email Address
*
Required Action
Action
*
New Hire
Notice of Change
Rehire
Termination
Change Options
(Check all that apply)
Notice of Change Options
*
Pay Change
Department Change
Leave
Additional Benefits
Other, describe below
Other Change
*
Effective Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
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Year
Year
2016
2017
2018
2019
2020
Biographical Information
Banner ID
*
First Name
*
Last Name
*
POSN#
*
Position
*
Old POSN#
If applicable
Payroll Status
Type
*
Full-Time
Part-Time
Status
*
Salary
Hourly
Hours Per Week
Bi-Weekly Salary
$
Factor
Pays
Annual Salary
$
Department Information
Current Department Name
*
Current ORG
*
Current Account
*
New Department Name
*
New ORG
*
New Account
*
Payroll Leave Status
Leave Status
*
- Select -
Leave with benefits
Leave without benefits
Leave with pay
Leave without pay
Leave Special Instructions/Comments
Termination Information
Vacation Hours
*
Last Day Worked
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
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10
11
12
13
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22
23
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26
27
28
29
30
31
Year
Year
2016
2017
2018
2019
2020
2021
Term Date of Record
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2016
2017
2018
2019
2020
2021
Last Check Date
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2016
2017
2018
2019
2020
2021
Additional Benefits
In Lieu of Health Insurance (XL1)
$1000 Annually?
*
Yes, Selected
Not Applicable
Benefits Prorated Amount
$
Cell Phone Stipend (XCL)
Cell Phone Service Level
*
Level One--Voice Only--$60.00/month
Level Two--Voice & Text--$80.00/month
Level Three--Voice, Text & Data--$115.00/month
Not Applicable
Cell Phone Prorated Amount
$
Additional Information/Comments
Information/Comments
