Employee Form Packets

Forms for new employees can be found in the New Employee Orientation.

Select form packet... Board and Commissioner Members Hire Board and Commissioner Members Separation Current State Employee Position Change Family Medical Leave GGU Separating IBU Separating KK Separating Layoff Long Term Non Perm Separating LTC Separating MEBA Separating Military Leave (To) Military Leave (Return from) MMP Separating Name Change PSEA Separating PX/EX Hiring Packet PX/EX Separating Return from Seasonal Leave Without Pay Short Term Non Perm Separating Status Change SU Separating To Seasonal Leave Without Pay Transfer out of Dept

Board and Commission Members Hire Packet

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Reminder: In accordance with AS 39.50.020, members of certain boards and commissions and other “public officials” as defined under AS 39.50.200 are required to file a Public Official Financial Disclosure (POFD) within 30 days of appointment.

Form	Requirement
Acknowledgment Form (PDF)	Mandatory
Address Authorization (PDF)	Mandatory
Alaska Supplemental Annuity Plan Beneficiary Designation (PDF)	Mandatory
Attendance Sheet (PDF)	Mandatory
APOC Filing Information (PDF)	Mandatory
Designation of Beneficiary for Unpaid Compensation (PDF)	Mandatory
Employment Eligibility Verification (I-9) (PDF)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Social Security Form (SSA-1945) (PDF)	Mandatory
W-4 Form (Employee Withholding Allowance Certificate) (PDF)	Mandatory
Payroll Direct Deposit Form (PDF) (PDF)	Optional

Board and Commission Members Separation Packet

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Reminder: In accordance with AS 39.50.020, members of certain boards and commissions and other “public officials” as defined under AS 39.50.200 are required to file a final Public Official Financial Disclosure (POFD) within 90 days of leaving state service.

Form	Requirement
Attendance Sheet (PDF)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
APOC Filing Information (PDF)	Mandatory
Address Authorization (PDF)	Optional
SBS-Annuity Withdrawal Form (PDF)	Optional

Current State Employee Position Change (Transfer, etc.)

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Form	Requirement
Confidentiality of Information Acknowledgement Form (PDF)	Mandatory
Drug Free Workplace Act (PDF)	Mandatory
Employee Affidavit Oath of Office and Emergency Contacts (PDF)	Mandatory
Emergency Contacts (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Ethics Disclosure: Outside Employment or Services Notification (if applicable) (PDF)	Mandatory
GGU Health Trust Notification Form (BU Change to or from GGU)	Mandatory
LTC Health Trust Notification Form (BU change to or from LTC) (PDF)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Pre-Employment Certification Form (PDF)	Mandatory
Statewide Policy Acknowledgement Form (PDF) Statewide Policies The following are the Administrative Orders that you are required to read. The Acknowledgement form needs to be printed and signed, acknowledging that the employee has read the information. Family and Medical Leave Act (PDF) Administrative Order 75 - EEO Policy Administrative Order 81 - Harassment Policy Administrative Order 129 - ADA Policy Administrative Order 195 - Diversity Policy Business Use/Acceptable Use ISP-172 (Personal Use of Office Technology Policy) (PDF) State of Alaska Ethics Information for Public Employees (AS 39.52) Policy on Seat Belts (AO 85) Effects of Violations of Federal or State Law (2 AAC 07.416)	Mandatory
Union Notification Form (BU Change) (Print and Sign) (PDF) OR Union Notification for ASEA (GGU) (PDF)	Mandatory
Address Authorization (PDF)	Optional
Basic Life and AD&D Insurance Beneficiary Designation Form (PDF)	Optional
Beneficiary Forms (PERS/TRS/Deferred Comp/SBS-Health/Optional Benefits) (includes "Designation of Beneficiary for Unpaid Compensation")	Optional
Payroll Direct Deposit Form (PDF) (PDF)	Optional
SBS/AlaskaCare Enrollment Information - ENROLL NOW (Enrollment is only available online)	Optional
Supervisor Checklist / Current Employee Forms (PDF)	Optional
Supervisor Guide to New Employee Orientation (PDF)	Optional
W-4 Form (Employee Withholding Allowance Certificate) (PDF)	Optional

Exempt and Partially Exempt (EX and PX) Hiring Packet

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Reminder: In accordance with AS 39.50.020, members of certain boards and commissions and other “public officials” as defined under AS 39.50.200 are required to file a Public Official Financial Disclosure (POFD) within 30 days of appointment.

Form	Requirement
Address Authorization (PDF)	Mandatory
Alaska Supplemental Annuity Plan Beneficiary Designation (PDF)	Mandatory
APOC Filing Information (PDF)	Mandatory
Basic Life and AD&D Insurance Beneficiary Designation Form (PDF)	Mandatory
Confidentialityof Information Acknowledgement Form (PDF)	Mandatory
Defined Contribution or Defined Benefits Retirement Plan Beneficiary Designation Form (PERS/TRS) Complete instructions are on these forms; verify that percentage total equals 100%. Employee signature/date and witness signature/date required. The completed forms must be forwarded to R&B to be considered a valid designation. PERS Tier IV / TRS Tier III employees complete the following forms if first appointed to a PERS/TRS position on or after 07/01/06. Beneficiary Designation 401(a) Plan - State of Alaska Public Employee's Tier IV Defined Contribution Retirement Plan 98214-04 (PDF) Beneficiary Designation 401(a) Plan - State of Alaska Teachers' Retirement System Tier III Defined Contribution Retirement Plan 98214-05 (PDF) or PERS Tier I/II/III / TRS Tier I/II employees appointed to a PERS/TRS position prior to 07/01/06 complete the following form: Beneficiary Designation Defined Benefit Plan Form (PDF)	Mandatory
Designation of Beneficiary For Unpaid Compensation (PDF)	Mandatory
Drug-free Workplace Act (PDF)	Mandatory
Employee Affidavit Oath of Office and Emergency Contacts (PDF)	Mandatory
Emergency Contacts (PDF)	Mandatory
Employee Eligibility Verification (I-9) (PDF)	Mandatory
Equal Employment Opportunity Survey (PDF)	Mandatory
Ethics Disclosure: Outside Employment or Services Notification (PDF) (if applicable)	Mandatory
Nepotism Waiver (PDF) (if applicable)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Post Hire Questionnaire for Second Injury Fund Qualification (PDF)	Mandatory
Pre-Employment Certification Form (PDF)	Mandatory
Prior Service Verification (PDF) (if applicable)	Mandatory
SBS/AlaskaCare Enrollment Information - ENROLL NOW (Enrollment is only available online)	Mandatory
Social Security Form (SSA-1945) (PDF)	Mandatory
W-4 Form (Employee Tax Withholding Allowance Certificate) (PDF)	Mandatory
Statewide Policy Acknowledgement Form (PDF) Statewide Policies The following are the Administrative Orders that you are required to read. The Acknowledgement form needs to be printed and signed, acknowledging that the employee has read the information. Family and Medical Leave Act (PDF) Administrative Order 75 - EEO Policy Administrative Order 81 - Harassment Policy Administrative Order 129 - ADA Policy Administrative Order 195 - Diversity Policy Business Use/Acceptable Use ISP-172 (Personal Use of Office Technology Policy) (PDF) State of Alaska Ethics Information for Public Employees (AS 39.52) Policy on Seat Belts (AO 85) Effects of Violations of Federal or State Law (2 AAC 07.416)	Mandatory
Deferred Compensation Plan (Enrollment and Beneficiary Designation Forms)	Optional
Payroll Direct Deposit Form (PDF)	Optional
Select Life and AD&D Insurance Beneficiary Designation Form (PDF)	Optional
Voluntary Supplemental Life and AD&D Insurance Beneficiary Designation Form (PDF)	Optional

GGU Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
GGU Health Trust Notification Form (PDF) (to notify Health Trust of separation from employment)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
TRS Claim and Verification of Unused Sick Leave Credit (PDF) (if retiring)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

IBU Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
IBU Separation Cover Letter (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

KK Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

LTC Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
LTC Health Trust Notification Form (PDF)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

MEBA Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
MEBA Separation Cover Letter (PDF)	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

MMP Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
MMP Separation Cover Letter (PDF)	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

PSEA Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Exit Survey	Optional
DPS State Trooper Exit Survey (Mandatory for Separating Troopers Only)	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

Exempt and Partially Exempt (EX and PX) Separating (Leaving State Employment or Retiring)

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Reminder: In accordance with AS 39.50.020, members of certain boards and commissions and other “public officials” as defined under AS 39.50.200 are required to file a final Public Official Financial Disclosure (POFD) within 90 days of leaving state service.

Form	Requirement
APOC Filing Information (PDF)	Mandatory
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
TRS Claim and Verification of Unused Sick Leave Credit (PDF) (if retiring)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

SU Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
PERS / TRS / Deferred Comp Refund Election Forms	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
TRS Claim and Verification of Unused Sick Leave Credit (PDF) (if retiring)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

Transfer out of Dept

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Form	Requirement
Employment Clearance Form (PDF)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Timesheet	Mandatory
Exit Survey	Optional
Letter of Resignation	Optional

Long Term Non Perm Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
GGUHealth Trust Notification Form (PDF) (to notify Health Trust of separation from employment) (GGU Only)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
LTC Health Trust Notification Form (PDF) (LTC Only)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
Terminal Leave Payoff Tax Option Form (PDF) (25% Flat Tax Option)	Optional
TRS Claim and Verification of Unused Sick Leave Credit (PDF) (if retiring)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

Short Term Non Perm Separating (Leaving State Employment or Retiring)

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Form	Requirement
Checkoff List for Separating Employees (PDF)	Mandatory
Employment Clearance Form (PDF)	Mandatory
Leaving State Employment Information	Mandatory
Letter of Resignation	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Exit Survey	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
W-4P Form (Withholding Certificate for Pension or Annuity Payments) (PDF)	Optional

To Seasonal Leave Without Pay

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Form	Requirement
Employment Clearance Form (PDF)	Mandatory
GGUHealth Trust Notification Form (PDF) (to notify Health Trust of separation from employment) (GGU Only)	Mandatory
LTC Health Trust Notification Form (PDF) (LTC Only)	Mandatory
Performance Evaluation (DOC)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Seasonal Employee Leave Retention GGU/LTC/SU (PDF)	Mandatory
Separating Employee Health Insurance Notice (PDF)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Basic & Select Life Insurance Enrollment Form or Change Form (PDF)	Optional
Beneficiary Forms (PERS/TRS/Deferred Comp/SBS-Health and Optional Benefits)	Optional
Deferred Compensation and other changes	Optional
Designation of Beneficiary for Unpaid Compensation	Optional

Return From Seasonal Leave Without Pay

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Form	Requirement
GGUHealth Trust Notification Form (PDF) (to notify Health Trust of separation from employment) (GGU Only)	Mandatory
LTC Health Trust Notification Form (PDF) (LTC Only)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Address Authorization (PDF)	Optional
Basic & Select Life Insurance Enrollment or Change Form (PDF)	Optional
Beneficiary Forms (PERS/TRS/Deferred Comp/SBS-Health and Optional Benefits) (includes "Designation of Beneficiary for Unpaid Compensation")	Optional
GGUHealth Trust Insurance Deferral (PDF) (GGU Only)	Optional
GGU Overtime/Compensatory Time Option Form (PDF) (GGU Only)	Optional
Payroll Direct Deposit Form (PDF) (PDF)	Optional
SBS/AlaskaCare Enrollment Information - ENROLL NOW (Enrollment is only available online)	Optional
Timesheet	Optional
W-4 Form (Employee Withholding Allowance Certificate) (PDF)	Optional

Status Change

(Marriage/Divorce/Birth of a Child/Employment Status Change/Name Change)

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Form	Requirement
Marriage Certificate / Divorce Decree / Birth Certificate (whichever is applicable)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Social Security Card Application (Mandatory for Name Change Only)	Mandatory
Address Authorization (PDF)	Optional
Basic & Select Life Insurance Enrollment or Change Form (PDF)	Optional
Beneficiary Forms (PERS/TRS/Deferred Comp/SBS-Health and Optional Benefits) (includes "Designation of Beneficiary for Unpaid Compensation")	Optional
Deferred Compensation Plan Forms (DCP)	Optional
Employee Affidavit Oath of Office and Emergency Contacts (PDF)	Optional
Emergency Contacts (PDF)	Optional
GGUHealth Trust Notification Form (PDF) (to notify Health Trust of separation from employment) (GGU Only)	Mandatory
LTC Health Trust Notification Form (PDF) (LTC Only)	Mandatory
Payroll Direct Deposit Form (PDF)	Optional
SBS/AlaskaCare Enrollment Information - ENROLL NOW (Enrollment online only to add or update dependents (if applicable))	Optional
W-4 Form (Employee Withholding Allowance Certificate) (PDF)	Optional

Family Medical Leave

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Form	Requirement
Certification of Health Care Provider (PDF)	Mandatory
Conditional Family Leave Notification (PDF)	Mandatory
Your Rights Under the Family and Medical Leave Act of 1993 (PDF)	Mandatory

Layoff

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Form	Requirement
Conditions of Employment Upon Return From Layoff (GGU and SU) (DOC)	Mandatory
Employment Clearance Form (PDF)	Mandatory
GGUHealth Trust Notification Form (PDF) (to notify Health Trust of separation from employment) (GGU Only)	Mandatory
GGU Layoff Information Sheet (PDF) (GGU Only)	Mandatory
LTC Health Trust Notification Form (PDF) (LTC Only)	Mandatory
LTC Layoff Information Sheet (PDF) (LTC Only)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Separating Employee Health Insurance Notice	Mandatory
SU Layoff Information Sheet (PDF) (SU Only)	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
SBS/Annuity Benefit Withdrawal Form (PDF)	Optional
COBRA Health Continuation Information for AlaskaCare	Optional
Exit Survey	Optional
LeavingState Employment Information	Optional

To Military Leave

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Form	Requirement
Copy of Military Orders	Mandatory
Employment Clearance Form (PDF)	Mandatory
Military Leave Benefit Election Form (PDF)	Mandatory
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Beneficiary Forms (PERS/TRS/Deferred Comp/SBS-Health and Optional Benefits) (includes "Designation of Beneficiary for Unpaid Compensation")	Optional
W-4 Form (Employee Withholding Allowance Certificate) (PDF)	Optional

Return from Military Leave

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Form	Requirement
Personnel Action Request Form (PARF) PDF/Excel	Mandatory
Timesheet	Mandatory
Address Authorization (PDF)	Optional
Beneficiary Forms (PERS/TRS/Deferred Comp/SBS-Health and Optional Benefits) (includes "Designation of Beneficiary for Unpaid Compensation")	Optional
Payroll Direct Deposit Form (PDF) (PDF)	Optional
W-4 Form (Employee Withholding Allowance Certificate) (PDF)	Optional