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Congratulations and Welcome. You have successfully completed all pre-employment
requirements with the City of Tampa.
To prepare for Orientation, please complete the New Hire forms below. Please read
each page carefully and make sure they are complete. Please Do Not Sign any of the
documents included in the packet until you are instructed to do so at Orientation.
Note: For direct deposit purposes, please add your Bank ID (Routing Number) and
Account Numbers to the Direct Deposit form (If you do not have a bank account, you
must establish one prior to your first day of employment). Type your name, last four
digits of your social security number and list the desired beneficiary(s) on the
Beneficiary Designation form.
All documents requiring a notary signature will be notarized during Orientation.
Once you have completed these documents, please print them and bring with you to
Orientation, along with the documents required for I-9 verification. (Social Security
Card, Driver’s License, etc.)
If you are unable to print the documents, you can come to the Employment Services
Division (315 E. Kennedy Blvd, 2
nd
Floor of Old City Hall) no later than 4:00 pm on the
Thursday prior to your Orientation date to use the lobby kiosk to complete and print the
paperwork.
If you have any questions, please feel free to contact us at 813-274-8911.
OATH OF LOYALTY
(As required by Section 876.05, F.S.)
I,
(First Name, MI, Last Name)
a citizen of the State of Florida and of the United States of America (A no
n
-
citizen may delete and
substitute appropriate words which describe his or her particular situation), and being employed by or
an officer of the City of Tampa, Florida, and a recipient of public funds as such employee or officer, do
hereby solemnly swear or affirm that I will support the Constitution of the United States and of the
State of Florida.
Employee ID#
State of Florida, County of
Hillsborough
EMPLOYEE’S SIGNATURE: DEPARTMENT
AFFIDAVIT
Sworn to (or affirmed) and subscribed before me on____/ / _____
,
by ________________________________________
NOTARY PUBLIC-STATE OF FLORIDA
SIGNATURE OF NOTARY PUBLIC
Type of Identification Produced
Drivers License/ID#
Instructions and General Information
The City of Tampa Ethics Code, Section 2-511, mandates disclosure of non-City employment/private business entity by July 1
st
of each year. On January 27, 2006, the Ethics Code was amended to require that all employees must have approval by their
department director (or the approval of the Mayor for Department Directors) of any non-city employment or active participation
in a private business entity (Section 2-512). The definition of a private business entity is provided on the front of this form.
Further clarification is provided below.
As provided in Section 2-512: “In determining the acceptability of such employment or activity, the department director shall
review all factors relevant to the successful and fair operation of city business, including but not limited to, potential conflict with
business hours, misuse of confidential information, or impairment of the performance of the city employee’s duties and
responsibilities. If the department director determines such non-city employment or engagement in a private
business entity is prohibited, that decision shall be automatically appealed to the Ethics Commission for review. All
department directors must obtain prior approval from the Mayor before accepting non-city employment or actively participating in
any business entity. The mere ownership of stock in a privately held or publicly traded company shall not constitute active
participation in that business entity. Serving as an officer, director, or owning a controlling financial interest therein shall
constitute active participation.” Section 2-502 defines “controlling financial interest” as the “ownership, directly of indirectly, to ten
(10) percent or more of the outstanding capital stock in any corporation or a direct or indirect interest or position in a business
entity sufficient to allow him or her to control its operation.”
• Name, Address, and Telephone Number of non-city employment/private business entity:
In the event that the paycheck or other remuneration is issued or received with a name different than the name of the
business, specify this name as well as the name commonly known as the name of the business. This includes situations
where the business uses a fictitious name, assumed name or D/B/A (short for “doing business as”). It is the employee’s
responsibility to ensure that the name of the non-city employment/private business entity is fully disclosed and fully
understood. Sworn police and fire employees, in the event that the business operates from their own home address, are not
required to disclose that address or telephone number on this form and should enter “Personal Residence” for the address to
maintain confidentiality permitted by state law. Sworn police and fire employees are not required to disclose extra-duty
positions when these positions are supplied and scheduled through their departmental programs.
• Brief description of the purpose and activities of the non-city employer/private business entity; Position; Relationship
in and to the business; Nature and extent of any ownership interest in the business:
These sections are provided for the employee to further disclose information that permits the approval of the employee’s non-
city employment/private business entity. Include information that would answer the following questions:
• What is the purpose and activity of the non-city employer/business entity, such as to sell products, make investments,
buy or sell real estate?
• Does the non-city employer or business entity have now, or in the past, any contract with, render any services to, submit
any bids to contract with the city or any of its agencies or departments? Does the employee have a role in this process or
make any decisions regarding these contracts on behalf of either the city or the non-city employer/private business
entity?
• Does the non-city employer or business entity purchase, rent or lease realty, goods, or services to the city or any of its
agencies or departments? Does the employee have a role in this process or make any decisions regarding these transactions
on behalf of either the city or the non-city employer/private business entity?
• What position will the employee hold? Will the position cause the employee to improperly use confidential information that
is available to the employee only because of their position with the city? Would the position impair or reasonably be
expected to impair the employee’s ability to make fair and independent judgments in performance of their city duties and
responsibilities? Would the employee’s involvement with non-city employment/private business entity cause the employee to
misuse his city position in any manner, such as co-workers or subordinates thinking they should buy a product that the
employee promotes or use services from a certain firm or business?
• Will the number of hours and the hours of the day that the employee participates affect or conflict with the employee’s ability
to perform city assigned duties? Employees are prohibited from performing non-city work during their city work hours and
are prohibited from the use of city property, such as telephones, computers, copiers, vehicles, etc., for personal use/gain or
any non-city purpose.
• Will the employee or any member of his or her immediate family or close personal relation receive any substantial benefit or
profit from any contract or obligation entered into between the city department for which the employee works and the non-
city employer or private business entity in which the employee is or may be involved?
• Does the employee have any active professional licenses, certifications, and/or permits and does the employee actively
engage in or plan to actively engage in any activity requiring its use?
Approval of the participation in non-city employment/private business entity does not relieve an employee of responsibility for
continued compliance with the City of Tampa Ethics Code. Prior approval of the participation may be removed at any time should
activity by the employee or by the non-city employer/private business entity or any additional information result in a revised
determination.
Non-City Employment/Private Business Entity Disclosure and Approval
The CITY OF TAMPA ETHICS CODE requires the mandatory disclosure by officials and employees of non-city employment or private
business entity (see Sec.2-511). Approval of such non-city employment/active participation in a private business entity by the
department director (or the Mayor for department directors) is required (Sec 2-512). Employees are considered to be “engaged in non-
city employment” if they have or hold an employment relationship with any entity other than the City of Tampa. Employees are
considered to be “engaged in a private business entity” if they own or operate a business entity defined as a corporation, partnership,
limited partnership, limited liability corporation, limited liability partnership, proprietorship, firm, enterprise, franchise, association, self-
employed individual or trust, whether fictitiously named or not.
See the reverse side of this form for additional instructions and information for completion of the form.
Employee Name:
Type Full Name: (First, Mi, Last)
Department/Division:
Employee Identification Number:
City Job Title/Position Name:
Check one box in this section and follow the instructions for the box you selected.
I am not engaged in any non-city employment or active participation in a private business entity.
If you checked this box, complete the final section of this form (employee/official signature area only).
I am requesting approval of non-city employment or active participation in a private business entity.
If you checked this box, you must complete the information below.
Name and Address of non-city employment/private business entity:
Name:________________________________________________________________________________________
Address:_____________________________________________________________________________________
____________________________________________________________________________________________
Telephone #:________________________________________________________________________________
Brief description of the purpose and activities of the non-city employer or private business entity:
______________________________________________________________________________________________
______________________________________________________________________________________________
Position:___________________________________________________________________________________
Relationship in and to the business:__________________________________________________________________
Nature and extent of any ownership interest in the business:______________________________________________
If you have more than one outside employment/private business entity, you must attach additional sheets
With information for each employment/private business entity.
Check here if continued on an additional sheet
Total number of forms, including this page _________
I certify that the information disclosed above is correct. I further understand that in addition to the annual report to be filed
with the City by July 1 of each year, any changes to the information completed on this form shall be filed within 30 days of
the change(s).
Employee/Official Signature:
Date Signed:
/ /
Non-City Employment/Private Business Entity is:
Approved
Disapproved
Department Director Signature:
Date Signed:
CITY OF TAMPA
DIRECT DEPOSIT AUTHORIZATION
I. EMPLOYEE INFORMATION
ID Dept
Employee Name: Last, First, MI
II. NET CHECK DIRECT DEPOSIT
New
Change
Cancel
No Change
Bank ID
Account #
III. PARTIAL DIRECT DEPOSIT
New
Change
Cancel
No Change
Bank ID
Account #
Amount $
IV. AUTHORIZATION
Any change in your bank identification number or account number now requires a pre-note. Pre-notes
are the first step in the direct deposit setup process, where any new bank routing number or account
number is verified electronically. During the first payroll cycle after a change in your direct deposit, you
will receive a PAPER CHECK by mail to your home address on record.
V. VERIFICATION
Verified By:_______________________________ Date___________
Dept. Personnel Assistant
VI. PROCESSING
Account Type
Checking
Savings
Account Type
Checking
Savings
I hereby
authorize
my employer to initiate credit entries and to
initiate, if necessary, debit entries and adjustments for any credit
entries in error to my (our) checking and/or savings account indicated
above and the depositories named above, each hereafter called
depository, to credit and/or debit the same to such account(s)
Date___________Signed_________________________
I hereby
cancel
the authority previously given to my employer by this
written notification from me of its termination in such time and in such
manner as to afford employer and the depository a reasonable
opportunity to act on it
Date___________Signed_________________________
PROCESSED BY
VERIFIED BY
Using transparent tape, attach the document
from your financial institution that shows
the bank routing number and account
number. Please do not staple.
DO NOT USE DEPOSIT SLIPS.
Using transparent tape, attach the document
from your financial institution that shows
the bank routing number and account
number. Please do not staple
DO NOT USE DEPOSIT SLIPS.
Fallen Heroes
Beneficiary Designation Form
Sponsored by Hillsborough County
Name (Last/First/MI)
Social Security Number
Employing Entity
Hillsborough County City of Tampa
Temple Terrace Plant City
Date of Hire
Date of Birth
Effective Date of Designation
Retain in Employee’s Personnel File
PRIMARY BENEFICIARY DESIGNATION
(Please Print Full Name)
Name __________________________________________________ Relationship __________________ % _______________
Address_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Address_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Address_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Address_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Addess:_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Address________________________________________________________________________________ {Must add to 100%}
CONTINGENT BENEFICIARY DESIGNATION
(Please Print Full Name)
Name __________________________________________________ Relationship __________________ % _______________
Address:_______________________________________________________________________________
Name _________________________________________________ Relationship __________________ %_______________
Address:_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Address:_______________________________________________________________________________
Name __________________________________________________ Relationship __________________ % _______________
Address:________________________________________________________________________________ {Must add to 100%}
Employee Signature
Date
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name: __________________________________________ Employee ID#: _________
(Type First Name, Middle Name, Last Name,Suffix)
Employer Name: CITY OF TAMPA Employer ID: 59-1101138
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a
pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your
own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security
benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your
Social Security benefit amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula
when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you
are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This
amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional
information, please refer to the Social Security publication, “Windfall Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will
be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax.
The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that
amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you
will receive $100 per month from Social Security, $500 - $400 = $100. Even if your pension is high enough to totally offset your
spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to
the Social Security publication, “Government Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision, are available at
www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or, for the deaf or hard of hearing, call the TTY number 1-800-
325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains Information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee: Date: ______________________
Form SSA-1945 (12-2004) EMPLOYEE COPY
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name: __________________________________________ Employee ID#: _________
(Type First Name, Middle Name, Last Name,Suffix)
Employer Name: CITY OF TAMPA Employer ID: 59-1101138
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a
pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your
own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security
benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your
Social Security benefit amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula
when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you
are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This
amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional
information, please refer to the Social Security publication, “Windfall Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will
be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax.
The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that
amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you
will receive $100 per month from Social Security, $500 - $400 = $100. Even if your pension is high enough to totally offset your
spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to
the Social Security publication, “Government Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision, are available at
www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or, for the deaf or hard of hearing, call the TTY number 1-800-
325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains Information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee: Date:_________________
Form SSA-1945 (12-2004) EMPLOYEE RELATIONS COPY
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name: __________________________________________ Employee ID#: _________
(Type First Name, Middle Name, Last Name,Suffix)
Employer Name: CITY OF TAMPA Employer ID: 59-1101138
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a
pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your
own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security
benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your
Social Security benefit amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula
when you are also entitled to a pension from a job where you did not pay Social Security tax. As
a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you
are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This
amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional
information, please refer to the Social Security publication, “Windfall Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will
be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax.
The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that
amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you
will receive $100 per month from Social Security, $500 - $400 = $100. Even if your pension is high enough to totally offset your
spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to
the Social Security publication, “Government Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each provision, are available at
www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or, for the deaf or hard of hearing, call the TTY number 1-800-
325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains Information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social
Security benefits.
Signature of Employee: Date: ___________________
Form SSA-1945 (12-2004) F&P PENSION OFFICE COPY
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Completed 16 July 2020

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