Deferred Compensation Participant
Rollover Form
- Active and Separating Employees
Mailing Address:
City of Oakland - Benefits Unit
150 Fran
k H Ogawa Plaza,
Suite 3341
Oakland, CA 94612
FAX: (510) 238-6560
Participant Name:
Mailing Address:
hereby authorize and direct my employer to deduct the following amount of hours from
my account and deposit the cash
equivalent into my Deferred Compensation Account.
understand that my deposit cannot exceed the maximum leave cash
out/buy-back allowed in my respective MOU and/or City policy and the statutory maximum annual IRS contribution.
Total Hours: _______________
Pay period end dat
e you wish to rollover to be processed:
(separating employees only)
Equivalent Dollar Amount (hours x hourly rate of pay): $
Notification of Acceptance
Deferred Compensation Plans
I hereby agree to defer my right to receive compensation in lieu of having my comp time, management leave,
and/or vacation leave hours deposited into my deferred compensation account up to the
maximums allowed
per IRS regulations and my respective MOU and/or City policy.
icipant Signature Da
mental Payroll Representative Signatur
e Date
Plan Administrator
Signature Date
*Active Employees: Rollover hours must be verified by your Department Payroll Representative to confirm
compliance with applicable MOU and City leave cash out/buy-back limits. Your form must be turned in by the second
week of June or by the
second week of December to be processed. Once received, monies will be
transferred to your deferred compensation account within 30 business
days from your date of request.
Compensatory Time*
Management Leave*
Sick Leave (employees separating from Service)
Zip Code
For HR Use Only
Deferred Comp:
or Employee ID:
# of Hours
Separation Date (if applicable):
Please indicate which account you would like your hours deducted from:
Street Address
Deferred Compensation Participant Rollover Form Instructions
1. Complete form and submit to your department payroll representative.
Department Payroll Representative
1. Verify the employee’s rollover hours do not exceed the cash out/buy-back maximum allowed
in the employee’s respective Memorandum of Understanding (MOU) and/or City policies.
2. If the requested rollover hours exceed the applicable MOU and/or City cash out/buy-back
limit, request that the employee revise the form accordingly.
3. If the requested rollover hours are in compliance with applicable MOU and/or City cash
out/buy-back limit:
a. Sign form
b. Submit form to:
Lisa Lavatai Benefits Representative
150 Frank Ogawa Plaza, Suite 3332
Oakland, CA 94612
FAX to (510) 238-2976