Fillable 2020 MCD Allowance Request Form 111219 (North Carolina State University)

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2020 MCD Allowance Request Form 111219 (North Carolina State University)

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Mobile Communication Device Allowance Request Form
This form is required to initiate and re-certify annually (by December 31 of each year) an employee’s eligibility and approval to receive
an employer-paid allowance for business use of their personal mobile communication device (MCD), or to receive a university owned MCD
to be used for business purposes only. Also use this form to document the termination of an employee’s participation in this plan.
Instructions: Complete all sections of the Mobile Device Allowance Request Form and obtain the appropriate signatures. Scan the form
into an electronic format and email it to cell_phone_forms@ncsu.edu. Include the current bill for the mobile device with the
request documents. ***To terminate an allowance, complete the biographic data portion of this form, select "Terminate" as the Request
Type , and enter the new Allowance End Date. Email the termination request to khkelley@ncsu.edu.
Revised
11/2019
Employee ID:
Division/Dept:
City:
State: Zip:
Allowance End Date:
Request Type:
Charge to Project ID:
Q2. Eligible Allowance Amount - Use your current cell phone bill to enter the informaon below.
A. What is the billing date of your current bill?
B. What are the total number of Device Lines included on your plan? This includes
mobile lines for cell phones, tablets, mobile hotspots, USB Modems, WiFi Card, etc.
C. What is the Base Plan Amount for all lines included on your
plan, minus any discounts?
Total
Maximum Allowance Amount Eligible
Monthly Allowance Amount
Determine Allowance Eligibility
Q1. Device Eligibility
A. What Type of Device is being used for university business?
B. Is the mobile device University Owned or Employee Owned?
C. What is the Mobile/Cellular Number for the device?
÷
÷
÷
=
=
=
Allowance Begin Date:
Employee Name:
Home Address:
D. What is the amount of any Surcharges and Misc. Fees for all lines, such as the
Federal Universal Service Fund?
E. What is the total amount of any Government Fees & Taxes for all lines?
F. Does line have any individual line charges for services or fees,
such as a Line Access Fee , Additional Data, Individual Government Fees and
Taxes, or an International plan? What is the total of these fees, minus any
discounts? Do not include equipment charges, insurance charges, or one time
fees in the total.
CLEAR
PRINT
SELECT ONE
12/31/2020
SELECT ONE
SELECT ONE
(000) 000-0000
1
1
0.00
0.00
1
1
0.00
(000) 000-0000
0.00
Mobile Communication Device Allowance Request Form
Revised
11/2018
Q3. What is your business-use juscaon for this request? Check only one.
Eligible senior-level employees which includes: the Chancellor, Execuve Ocers, Deans, and other JCAT 100-level posions
as designated by the Chancellor or the appropriate Vice Chancellor.
Faculty and non-faculty professionals who must be available 24/7 or during non-business hours to meet service needs such
as life/safety issues and/or crical system and operaonal support.
Faculty and non-faculty professionals who must be rounely accessible during business hours but are primarily in travel
status or “in the eld” a signicant amount of the me due to the nature of job dues (job requirement to be away from a
standard oce). Review of the most ecient and cost eecve means of communicaon should be considered before
authorizing employees in this classicaon.
Q4. Are you an FLSA exempt permanent employee with a full me, twelve month appointment? Check only one.
Yes
No, but I am requesng an excepon.
In limited situaons, an MCD allowance may be issued to a non-exempt employee when their job responsibilies require
the frequent use of their employee-owned device to accomplish University business. The Department Head or designee of
the non-exempt employee is responsible for documenng an excepon to the MCD policy. The non-exempt employee is
responsible for cerfying aer hours usage on the employee's monthly me sheet, which the supervisor must approve. The
Department Head or designee must complete an annual review of the business juscaon for the excepon. (Eecve,
May 2018)
If you are a non-exempt employee (subject to FLSA) with a full-me, twelve month appointment and would like to request
an MCD allowance, provide a unique business juscaon to request an excepon below.
Enter justification here.
1. NC State’s MCD allowances will be paid through accounts payable as non-taxable cell phone reimbursement. According to
the IRS, documentation of business use is required. Therefore, please attach a copy of your most recent cell phone bill to this
form. Employees and management must re-certify MCD allowances using this same approval process by December 31st each
year to be continued into the next calendar year. The cell phone bill must be in the employee’s name or address.
2. The University will not purchase nor replace cell phone or data devices for employees receiving a MCD allowance.
3. For involuntary employment terminations (e.g. RIF, dismissal), the University will pay applicable service cancellation fees.
4. Employees receiving a MCD will be required to have their cell phones and/or data device with them, charged and
operational at all times.
5. The allowance and records of associated business use will be subject to the Public Records Act.
6. This form should be used to document the termination of an employee’s participation in the MDC allowance plan.
Mobile Communication Device Allowance Request Form
Revised
11/2018
Employee Cercaon and Signature:
I cerfy that I will use the funds requested toward the business use
designated above, and promptly report any changes in the level of
those business expenses to my supervisor. I will maintain my mobile
communicaon device service and operaon for University business. I
further cerfy that I have read, understood and will comply with NC
State’s mobile communicaon device operang parameters described
above.
Supervisor & Department / University Head or Designee
Cercaon and Signatures:
I cerfy that the requested allowance is needed for this
employee, to cover University-related expenditures for the
mobile communicaon device services described above. I cerfy
that the allowance has been jused to NC State’s Mobile
Communicaon Device Allowance standard.
Employee’s Signature - Required Date
Employee’s Supervisor - Required Date
Dean/Director/Department Head - Required Date
MCD Allowance Cercaons
Operang Parameters
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2020 MCD Allowance Request Form 111219 (North Carolina State University)

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Completed 22 July 2020

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