Fill - Free fillable FullTime (Cisco College) PDF form

CiscoCollege–March24,2014

Full‐Time

Administrative

NewHire

Packet

(AcademicYear2019‐20)

New Employee Information

Title:

Last Name:

First Name:

Social Security #

Address:

City,State,Zip:

Home Phone:

Cell Phone:

____________________________________________

Cisco College IT Acceptable Use Policy:

Yes, I have read the Cisco College IT Acceptable

Use Policy.

Policy is available at: http://www.cisco.edu/

s/926/images/editor_documents/hr_forms/

ciscocollegepolicymanual-spring2016.pdf

Full Time Part Time

Primary Location

Cisco Abilene

FT/PT

PayCheck Disbursement:

I will pick up my check in Abilene

I will pick up my check in Cisco

I have Direct Deposit:

(please specify mail or pick up for first check)

Mail my paycheck to the following address:

__________________________________

_________________________________________________________________________________

____________________________________________________________________________________________________________

_________________________________________________________________________________

____________________________________________________________________________________________________________

(Click link above to view Policy)

Emergency Contact Person:

Relationship to Emergency Contact:

Emergency Contact Address:

Emergency Contact City, State, Zip:

________________________________________

__________________________________

_______________________________________

__________________________________

Emergency Contact Home phone: ____________________________________

Emergency Contact Work Phone: ____________________________________

Emergency Contact Cell Phone: _____________________________________

Highest Degree Earned:

Ethnicity:

Employee Classification:

Home Phone Available to Students: Yes

Home Email Available to Students:

Yes

Employee Signature: _________________________________Date: ____________________

_________________________________________________________________________________

____________________________________________________________________________________________________________

_________________________________________________________________________________

Job Title:______________________________________________________

Faculty Position:

Division:

Hire Date: _____________________________

Home Email: ___________________________________________________

____________________

__________________________

______________________________

_____________________________

______________________________

BIOGRAPHIC REPORT

NAME:______________________________________________________________________

ADDRESS:__________________________________________________________________

Street City State Zip

Telephone Number:____________________________________________________________

Social Security Number:________________________________________________________

Highest Degree or Certificate:____________________________________________________

Institution of Highest Degree:____________________________________________________

Area of Specialization:__________________________________________________________

Date of Birth:_________________________________________________________________

Total Teaching Experience:______________________________________________________

Date of Employment:___________________________________________________________

Job Title:____________________________________________________________________

Teaching Experience at Cisco College:_____________________________________________

Teaching Experience other than Cisco College:______________________________________

Ethnic origin – Please check only one:

American-Indian/Alaskan Native _______

Asian _______

Black _______

Hispanic _______

White _______

Other _______ Date:__________________

Form W-4

2020

Employee’s Withholding Certificate

Department of the Treasury

Internal Revenue Service

▶

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

▶

Give Form W-4 to your employer.

▶

Your withholding is subject to review by the IRS.

OMB No. 1545-0074

Step 1:

Enter

Personal

Information

(a) First name and middle initial Last name

Address

City or town, state, and ZIP code

(b) Social security number

▶

Does your name match the

name on your social security

card? If not, to ensure you get

credit for your earnings, contact

SSA at 800-772-1213 or go to

www.ssa.gov.

(c)

Single or Married filing separately

Married filing jointly (or Qualifying widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can

claim exemption from withholding, when to use the online estimator, and privacy.

Step 2:

Multiple Jobs

or Spouse

Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse

also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b)

Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c)

If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option

is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .

▶

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment

income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will

be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:

Claim

Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000

▶

Multiply the number of other dependents

by $500 . . . .

▶

Add the amounts above and enter the total here . . . . . . . . . . . . .

3 $

Step 4

(optional):

Other

Adjustments

(a)

Other income (not from jobs). If you want tax withheld for other income you expect

this year that won’t have withholding, enter the amount of other income here. This may

include interest, dividends, and retirement income . . . . . . . . . . . .

4(a) $

(b)

Deductions. If you expect to claim deductions other than the standard deduction

and want to reduce your withholding, use the Deductions Worksheet on page 3 and

enter the result here . . . . . . . . . . . . . . . . . . . . .

4(b) $

4(c)

Step 5:

Sign

Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

▲

Employee’s signature (This form is not valid unless you sign it.)

▲

Date

Employers

Only

Employer’s name and address First date of

employment

Employer identification

number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Cat. No. 10220Q

Form W-4 (2020)

Page 2

General Instructions

Future Developments

For the latest information about developments related to

Form W-4, such as legislation enacted after it was published,

go to www.irs.gov/FormW4.

Purpose of Form

Complete Form W-4 so that your employer can withhold the

correct federal income tax from your pay. If too little is

withheld, you will generally owe tax when you file your tax

return and may owe a penalty. If too much is withheld, you will

generally be due a refund. Complete a new Form W-4 when

changes to your personal or financial situation would change

the entries on the form. For more information on withholding

and when you must furnish a new Form W-4, see Pub. 505.

Exemption from withholding. You may claim exemption from

withholding for 2020 if you meet both of the following

conditions: you had no federal income tax liability in 2019 and

you expect to have no federal income tax liability in 2020. You

had no federal income tax liability in 2019 if (1) your total tax on

line 16 on your 2019 Form 1040 or 1040-SR is zero (or less

than the sum of lines 18a, 18b, and 18c), or (2) you were not

required to file a return because your income was below the

filing threshold for your correct filing status. If you claim

exemption, you will have no income tax withheld from your

paycheck and may owe taxes and penalties when you file your

2020 tax return. To claim exemption from withholding, certify

that you meet both of the conditions above by writing “Exempt”

on Form W-4 in the space below Step 4(c). Then, complete

Steps 1(a), 1(b), and 5. Do not complete any other steps. You

will need to submit a new Form W-4 by February 16, 2021.

Your privacy. If you prefer to limit information provided in

Steps 2 through 4, use the online estimator, which will also

increase accuracy.

As an alternative to the estimator: if you have concerns

with Step 2(c), you may choose Step 2(b); if you have

concerns with Step 4(a), you may enter an additional amount

you want withheld per pay period in Step 4(c). If this is the

only job in your household, you may instead check the box

in Step 2(c), which will increase your withholding and

significantly reduce your paycheck (often by thousands of

dollars over the year).

When to use the estimator. Consider using the estimator at

www.irs.gov/W4App if you:

1. Expect to work only part of the year;

2. Have dividend or capital gain income, or are subject to

additional taxes, such as the additional Medicare tax;

3. Have self-employment income (see below); or

4. Prefer the most accurate withholding for multiple job

situations.

Self-employment. Generally, you will owe both income and

self-employment taxes on any self-employment income you

receive separate from the wages you receive as an

employee. If you want to pay these taxes through

withholding from your wages, use the estimator at

www.irs.gov/W4App to figure the amount to have withheld.

Nonresident alien. If you’re a nonresident alien, see Notice

1392, Supplemental Form W-4 Instructions for Nonresident

Aliens, before completing this form.

Specific Instructions

Step 1(c). Check your anticipated filing status. This will

determine the standard deduction and tax rates used to

compute your withholding.

Step 2. Use this step if you (1) have more than one job at the

same time, or (2) are married filing jointly and you and your

spouse both work.

Option (a) most accurately calculates the additional tax

you need to have withheld, while option (b) does so with a

little less accuracy.

If you (and your spouse) have a total of only two jobs, you

may instead check the box in option (c). The box must also be

checked on the Form W-4 for the other job. If the box is

checked, the standard deduction and tax brackets will be cut

in half for each job to calculate withholding. This option is

roughly accurate for jobs with similar pay; otherwise, more tax

than necessary may be withheld, and this extra amount will be

larger the greater the difference in pay is between the two jobs.

▲

CAUTION

Multiple jobs. Complete Steps 3 through 4(b) on only

one Form W-4. Withholding will be most accurate if

you do this on the Form W-4 for the highest paying job.

Step 3. Step 3 of Form W-4 provides instructions for

determining the amount of the child tax credit and the credit

for other dependents that you may be able to claim when

you file your tax return. To qualify for the child tax credit, the

child must be under age 17 as of December 31, must be

your dependent who generally lives with you for more than

half the year, and must have the required social security

number. You may be able to claim a credit for other

dependents for whom a child tax credit can’t be claimed,

such as an older child or a qualifying relative. For additional

eligibility requirements for these credits, see Pub. 972, Child

Tax Credit and Credit for Other Dependents. You can also

include other tax credits in this step, such as education tax

credits and the foreign tax credit. To do so, add an estimate

of the amount for the year to your credits for dependents

and enter the total amount in Step 3. Including these credits

will increase your paycheck and reduce the amount of any

refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other

estimated income for the year, if any. You shouldn’t include

income from any jobs or self-employment. If you complete

Step 4(a), you likely won’t have to make estimated tax

payments for that income. If you prefer to pay estimated tax

rather than having tax on other income withheld from your

paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions

Worksheet, line 5, if you expect to claim deductions other than

the basic standard deduction on your 2020 tax return and

want to reduce your withholding to account for these

deductions. This includes both itemized deductions and other

deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want

withheld from your pay each pay period, including any

amounts from the Multiple Jobs Worksheet, line 4. Entering an

amount here will reduce your paycheck and will either increase

your refund or reduce any amount of tax that you owe.

Form W-4 (2020)

Page 3

Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE

Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional

tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one

job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the

“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter

that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $

2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and

2c below. Otherwise, skip to line 3.

Find the amount from the appropriate table on page 4 using the annual wages from the highest

paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job

in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries

and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a

Add the annual wages of the two highest paying jobs from line 2a together and use the total as the

wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower

Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount

on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2b $

c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c

3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays

weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this

amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional

amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $

Step 4(b)—Deductions Worksheet (Keep for your records.)

Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such

deductions may include qualifying home mortgage interest, charitable contributions, state and local

taxes (up to $10,000), and medical expenses in excess of 7.5% of your income . . . . . . . 1 $

2 Enter:

{

• $24,800 if you’re married filing jointly or qualifying widow(er)

• $18,650 if you’re head of household

• $12,400 if you’re single or married filing separately

}

. . . . . . . . 2 $

3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . 3 $

4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other

adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information 4 $

5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $

Privacy Act and Paperwork Reduction Act Notice. We ask for the information

on this form to carry out the Internal Revenue laws of the United States. Internal

Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to

provide this information; your employer uses it to determine your federal income

tax withholding. Failure to provide a properly completed form will result in your

being treated as a single person with no other entries on the form; providing

fraudulent information may subject you to penalties. Routine uses of this

information include giving it to the Department of Justice for civil and criminal

litigation; to cities, states, the District of Columbia, and U.S. commonwealths and

possessions for use in administering their tax laws; and to the Department of

Health and Human Services for use in the National Directory of New Hires. We

may also disclose this information to other countries under a tax treaty, to federal

and state agencies to enforce federal nontax criminal laws, or to federal law

enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is

subject to the Paperwork Reduction Act unless the form displays a valid OMB

control number. Books or records relating to a form or its instructions must be

retained as long as their contents may become material in the administration of

any Internal Revenue law. Generally, tax returns and return information are

confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary

depending on individual circumstances. For estimated averages, see the

instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear

from you. See the instructions for your income tax return.

Form W-4 (2020)

Page 4

Married Filing Jointly or Qualifying Widow(er)

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 -

9,999

$10,000 -

19,999

$20,000 -

29,999

$30,000 -

39,999

$40,000 -

49,999

$50,000 -

59,999

$60,000 -

69,999

$70,000 -

79,999

$80,000 -

89,999

$90,000 -

99,999

$100,000 -

109,999

$110,000 -

120,000

$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870

$10,000 - 19,999

220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070

$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900

$30,000 - 39,999

900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100

$40,000 - 49,999

1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220

$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220

$60,000 - 69,999

1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220

$70,000 - 79,999

1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240

$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460

$100,000 - 149,999

1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180

$150,000 - 239,999

2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250

$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170

$260,000 - 279,999

2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770

$280,000 - 299,999

2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370

$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970

$320,000 - 364,999

2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840

$365,000 - 524,999

2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280

$525,000 and over

3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650

Single or Married Filing Separately

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 -

9,999

$10,000 -

19,999

$20,000 -

29,999

$30,000 -

39,999

$40,000 -

49,999

$50,000 -

59,999

$60,000 -

69,999

$70,000 -

79,999

$80,000 -

89,999

$90,000 -

99,999

$100,000 -

109,999

$110,000 -

120,000

$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040

$10,000 - 19,999

940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830

$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110

$30,000 - 39,999

1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310

$40,000 - 59,999

1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080

$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060

$80,000 - 99,999

2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060

$100,000 - 124,999

2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620

$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370

$150,000 - 174,999

2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120

$175,000 - 199,999

2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230

$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930

$250,000 - 399,999

2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930

$400,000 - 449,999

2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540

$450,000 and over

3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300

Head of Household

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 -

9,999

$10,000 -

19,999

$20,000 -

29,999

$30,000 -

39,999

$40,000 -

49,999

$50,000 -

59,999

$60,000 -

69,999

$70,000 -

79,999

$80,000 -

89,999

$90,000 -

99,999

$100,000 -

109,999

$110,000 -

120,000

$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040

$10,000 - 19,999

830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440

$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850

$30,000 - 39,999

1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140

$40,000 - 59,999

1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360

$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380

$80,000 - 99,999

1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380

$100,000 - 124,999

2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870

$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620

$150,000 - 174,999

2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370

$175,000 - 199,999

2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980

$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870

$250,000 - 349,999

2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870

$350,000 - 449,999

2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200

$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240

USCIS

Form I-9

OMB No. 1615-0047

Expires 08/31/2019

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N

Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,

during completion of this form.

Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which

document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ

an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later

than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name) First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

U.S. Social Security Number

Employee's E-mail Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in

connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until

(See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1

Do Not Write In This Space

Signature of Employee

Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my

knowledge the information is true and correct.

Signature of Preparer or Translator

Today's Date (mm/dd/yyyy)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name)

City or Town

State

ZIP Code

Employer Completes Next Page

C I S C O

Form I-9 07/17/17 N

Page 2 of 3

USCIS

Form I-9

OMB No. 1615-0047

Expires 08/31/2019

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You

must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists

of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)

Employee Info from Section 1

Citizenship/Immigration Status

List A

Identity and Employment Authorization

Identity

Employment Authorization

OR List B AND List C

Additional Information

QR Code - Sections 2 & 3

Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,

(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the

employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):

(See instructions for exemptions)

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative

Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name)

City or Town

State

ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable)

Last Name (Family Name)

First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)

Date (mm/dd/yyyy)

Document Title Document Number

Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes

continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if

the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

Cisco College

101 College Heights

Cisco

76437

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be UNEXPIRED

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

LIST A

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machine-

readable immigrant visa

4. Employment Authorization Document

that contains a photograph (Form

I-766)

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

Documents that Establish

Both Identity and

Employment Authorization

6. Passport from the Federated States of

Micronesia (FSM) or the Republic of

the Marshall Islands (RMI) with Form

I-94 or Form I-94A indicating

nonimmigrant admission under the

Compact of Free Association Between

the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has

the following:

(1) The same name as the passport;

and

(2) An endorsement of the alien's

nonimmigrant status as long as

that period of endorsement has

not yet expired and the

proposed employment is not in

conflict with any restrictions or

limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are

unable to present a document

listed above:

1. Driver's license or ID card issued by a

State or outlying possession of the

United States provided it contains a

photograph or information such as

name, date of birth, gender, height, eye

color, and address

9. Driver's license issued by a Canadian

government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local

government agencies or entities,

provided it contains a photograph or

information such as name, date of birth,

gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish

Identity

LIST B

OR AND

LIST C

7. Employment authorization

document issued by the

Department of Homeland Security

1. A Social Security Account Number

card, unless the card

includes one of

the following restrictions:

2. Certification of report of birth issued

by the Department of State (Forms

DS-1350, FS-545, FS-240)

3. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

4. Native American tribal document

6. Identification Card for Use of

Resident Citizen in the United

States (Form I-179)

Documents that Establish

Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3

Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Employer Information

1. Federal Employer ID Number (FEIN): 2. State Employer ID Number (Optional):

Please use the same FEIN that appears on quarterly wage reports.

3. Employer Name:

4. Employer Address (Please indicate the address where the Income Withholding Orders should be sent):

5. Employer City (if US): 6. State (if US): 7. ZIP Code (if US):

8. Province/Region (if foreign): 9. Country (if foreign): 10. Postal Code (if foreign):

11. Employer Telephone (Optional): 12. Employer FAX (Optional):

13. New Hire Contact Person (Optional):

Employee Information

14. Social Security Number (SSN): 15. Date of Hire (MM/DD/YYYY):

16. Employee First Name:

17. Employee Middle Name:

18. Employee Last Name:

19. Employee Home Address:

20. Employee City (if US): 21. State (if US): 22. ZIP Code (if US):

23. Province/Region (if foreign): 24. Country (if foreign): 25. Postal Code (if foreign):

26. State Where Employee Was Hired (Optional): 27. Employee DOB (MM/DD/YYYY) (Optional):

28. Employee’s Salary (Dollars and Cents) (Optional):

29. Salary Frequency (Check One ONLY) (Optional):

Hourly

Weekly

Biweekly

Semi-Monthly

Monthly

Annually

Texas Employer New Hire Reporting Form

Submit within 20 calendar days of new employee’s

first day of work to:

ENHR Operations Center, P.O. Box 149224

Austin, TX 78714-9224

Phone: 1-800-850-6442 FAX: 1-800-732-5015

Online: www.employer.texasattorneygeneral.gov

To ensure the highest level of accuracy, please print neatly

in capital letters and avoid contact with the edges of the

boxes. The following will serve as an example:

REV 12/13 ENHR RPT FORM

7 5 1 1 6 4 3 4 3

C I S C O C O L L E G E

1 0 1 C O L L E G E H E I G H T S

C I S C O

T X

2 5 4 4 4 2 5 1 2 1

76437

INSTRUCTIONS FOR COMPLETING THE TEXAS EMPLOYER NEW HIRE REPORTING FORM

The purpose of the Texas New Hire Reporting Form is to allow employers to fulfill new hire reporting requirements. You may enter your

employer information and photocopy a supply and then enter employee information on the copies.

REPORTING OF NEW HIRES IS REQUIRED:

All required items (numbers 1, 3, 4, 5, 6, 7, 14, 15, 16, 17, 18, 19, 20, 21, 22) on this form must be completed.

Box 1: Federal Employer ID Number (FEIN). Provide the 9-digit employer identification number that the federal government assigns to the

employer. This is the same number used for federal tax reporting. Please use the same FEIN that appears on quarterly wage reports.

Box 2: State Employer ID Number (Optional). Identification number assigned to the employer by the Texas Workforce Commission.

Box 3: Employer Name. The employer name as listed on the employee’s W4 form. Please do not provide more than one employer name

(for example, “ABC, Inc DBA. John Doe Paint and Body Shop” is not correct).

Box 4: Employer Address. Please indicate the address where the Income Withholding Orders should be sent. Do not provide more

than one address (for example, P.O. Box 123, 1313 Mockingbird Lane is not correct).

Box 8: Employer Province/Region (if foreign). Provide this information if the employer address is not in the United States.

Box 9: Employer Country (if foreign). Provide the two letter country abbreviation if the employer address is not in the United States.

Box 10: Postal Code (if foreign). Provide the postal code if the employer address is not in the United States.

Box 13: New Hire Contact Person (Optional). Providing the name of a contact staff person will facilitate communication between the

employer and the Texas Employer New Hire Reporting Program.

Box 15: Date of Hire. List the date in month, day and year order. Use four digits for the year (for example, 2001). This should be the first

day that services are performed for wages by an individual. If you are reporting a rehire (where a new W-4 is prepared) use the return date,

not the original date of hire.

Box 23: Employee Province/Region (if foreign). Provide this information if the employee does not reside in the United States.

Box 24: Employee Country (if foreign). Provide the two letter country abbreviation if the employee address is not in the United States.

Box 25: Postal Code (if foreign). Provide the postal code if the employee address is not in the United States.

Box 26: State Where Employee was Hired. Use the abbreviation recognized by the U.S. Postal Service for the state in which the

employee was hired.

Box 27: Employee DOB (Date of Birth) (Optional). List the date in month, day and year order. Use four digits for the year (for example,

1985).

Box 28: Employee Salary (Optional). Enter employee’s exact wages in dollars and cents. This should correspond to the salary pay

frequency indicated in Box 29.

Box 29: Salary (Check One ONLY) (Optional). Check the appropriate box relating to the employee’s salary pay frequency. Check “ Bi-

weekly” if the salary is based on 26 pay periods. Check “Semi-monthly” if the salary is based on 24 pay periods. Check “Annually” if salary

payment is a one-time distribution.

SUBMISSION OF NEW HIRE REPORTS. The Texas Employer New Hire Reporting Program offers a variety of methods that employers

can use to submit new hire reports. For further information on which method may be best for you, call 1-800-850-6442. Employers are

encouraged to keep photocopies or electronic records of all reports submitted. When the form is completed, send it to the Texas Employer

New Hire Reporting Program using one of the following means:

 FAX: 1-800-732-5015

 U.S. Mail:

ENHR Operations Center

P.O. Box 149224

Austin, TX 78714-9224

 Telephone Submissions: 1-800-850-6442

 Internet Submissions: www.employer.texasattorneygeneral.gov

Employers must provide all of the required information within 20 calendar days of the employee's first day of work to be in

compliance. State law provides a penalty of $25 for each employee an employer knowingly fails to report, and a penalty of $500 for

conspiring with an employee to 1) fail to file a report or 2) submit a false or incomplete report.

REV 12/13 ENHR RPT FORM

DIRECT DEPOSIT AUTHORIZATION FORM

Name:_______________________________________________________________________

Last Name First Name MI

SSN:____________________________________

Payroll Type:



Semi-Monthy  Monthly

______START: I authorize you and the financial institution listed below to deposit my

net pay automatically to my account(s) each payday, and to initiate adjustments, if

necessary, for any entries made in error to my accounts.

______CHANGE Checking and/or Savings: I authorize you to change my direct deposit

to the account(s) at the financial institution listed below.

______STOP: I authorize you to stop the direct deposit of my net paycheck.

Institution Name__________________________ ________% of net check or $___________

Account Type: _____Checking _____Savings Account Number: _______________________

Bank Routing /Transit Number: ___ ___ ___ ___ ___ ___ ___ ___ ___

Signature: _______________________________________ Date: ___________________

Shaded Area for Payroll Use Only

Received

Prenoted Deposited

A VOIDED CHECK MUST BE PROVIDED IN THE SPACE BELOW

Routing/Transit Number -

Routing/Transit is a 9

-digit

number that identifies the

financial institution where

your checking account is

located.

Account Number - This is

your checking account

number.

Check Number - The financial institution scans the

check number electronically

in order for it to appear on

your monthly statement.

DIRECT DEPOSIT INFORMATION

1. The payroll deposit authorized by the employee’ signature on the Direct Deposit

Authorization form is accomplished by a process known as electronic funds transfer. It is

covered by a number of Federal regulations designed to safeguard the integrity of the

employee’s account

2. The funds deposited should be available to the employee for withdrawal by all regular

means on the morning of the scheduled payday.

3. The electronic funds transfer system requires an additional step known as pre-

notification. This is a procedure whereby account numbers must be verified by the

receiving financial institution before we will transmit direct deposit data to them.

Therefore new authorizations, changes, or cancellations should be in the Payroll

Department one month prior to the month the authorization, change or cancellation is to

take effect. If the authorization cannot be processed, Payroll will notify the employee,

who will continue to receive a payroll check until the authorization can be processed.

4. The pre-notification process also dictates that if a change in the financial institution or

account number is made, the employee must be removed from direct deposit for a

minimum of one pay period before the change will take effect. For the payday(s) the

employee will receive a payroll check(s).

5. Cisco College assumes no responsibility to issue a payroll check to any employee whose

direct deposit could not be processed due to his/her account being closed, or any other

reason, until the receiving financial institution has either refunded or guaranteed refund

of such deposit to the College.

RETURN

COMPLETED FORM TO:

Cisco College

Human Resources Office

101 College Heights

Cisco, TX 76437

EMPLOYEE HANDBOOK

I verify that I will read the Cisco College Employee Handbook. The handbook is

located on the Cisco College Website/Intranet at:

http://csacs01/policy/default.aspx

___________________________

Signature of Employee

___________________________

Date

Statement Concerning Your Employment in a Job

Not Covered by Social Security

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 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 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 Name Employee ID#

Employer Name Employer ID#

CISCO COLLEGE

Information about Social Security Form SSA-1945

Statement Concerning Your Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State

and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not

covered under Social Security. The statement explains how a pension from that job could affect future Social

Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the

document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential

effects of two provisions in the Social Security law for workers who also receive a pension based on their work in

a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s

Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social

Security benefit received as a spouse or an ex-spouse.

Employers must:

• Give the statement to the employee prior to the start of employment;

• Get the employee’s signature on the form; and

• Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/form1945.

Paper copies can be requested by email at oplm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The

request must include the name, complete address and telephone number of the employer. Forms will not be sent to

a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The

forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA-1945 (12-2004)

OATH OF OFFICE

In the name and by the authority of

STATE OF TEXAS

I, ______________________________________________do solemnly swear (or affirm), that

(Employee Name)

I will faithfully execute the duties of the office of ____________________________________

(Job Title - including subject if teaching)

Of the State of Texas, and will to the best of my ability preserve, protect, and defend the

Constitution and laws of the United States and of this State; and I furthermore solemnly swear

(or affirm), that I have not directly nor indirectly paid, offered, or promised to pay, contributed,

nor promised any public office or employment, as a reward to secure my appointment or the

confirmation thereof. So help me God.

__________________________________

Signature

Sworn to and Subscribed before me this

_________day of _____________, 20___

_____________________, Notary Public

_____________________, County, Texas

1000 Red River Street

Austin, TX 78701-2698

(800) 223-8778

www.trs.texas.gov

Teacher Retirement System of Texas Page 1 of 3

Section 1 - Member Information

Social Security NumberName

Address

Street Address or Box Number City State Zip Code

Phone Number

Date of Birth

Election to Participate in Optional

Retirement Program and/or Refund

TRS28 (09-16)

To be completed if your refund will be sent to a foreign address:

AreyouaU.S.citizen?

Yes No

If you are not a U.S. citizen, are you a resident alien of the U.S.?

Yes No

If you answered no to both questions above, see page 1 of the Information Sheet for ORP Election and/or Refund

(TRS28IN) for additional information regarding required federal income tax withholding.

Section 2 – Prior Optional Retirement Program Election Information

Have you previously elected the Optional Retirement Program in lieu of TRS?

Yes No

If yes, institution name __________________________________ dates of employment ___________________

If yes, you are not eligible to elect ORP a second time.

Section 3 – Member Election

I elect to participate in the Optional Retirement Program (ORP) established under Chapter 830, Texas Government

Code, in lieu of membership in the Teacher Retirement System of Texas (TRS). I understand that by this election I will

not be eligible for membership in TRS unless I cease to be employed by an institution of higher education and become

employed by the Texas public school system other than in an institution of higher education. I further understand that by

electing ORP, I forfeit all accrued rights to benefits from TRS, if any, including benefits based on TRS service credit

accrued prior to this election. I am entitled only to a refund of my TRS accumulated contributions, if any. I understand

this election is irrevocable.

Section 4 – Refund Election (select one)

Refund

I elect to have my TRS accumulated contributions paid directly to me. I understand that 20% of

the taxable amount of my refund will be withheld for federal income taxes (provided the

amount is greater than $200.00). See page 2 of the Information Sheet for ORP Election and/or

Refund (TRS28IN) for information on tax withholding if you are not a U.S. citizen or resident

alien of the U.S.

Direct Rollover

I elect to have all or a portion of my TRS accumulated contributions rolled over into an

eligible retirement plan. I understand that TRS will provide me with an additional form if this

option is selected. A Refund Rollover Election form (TRS6A) must be completed and returned

to TRS.

No Refund

I elect to leave my accumulated contributions with TRS. I understand that I forfeit all accrued

rights to benefits based on my TRS service credit accrued prior to my election to participate in

ORP, if any, by electing ORP in lieu of TRS. I understand that I can apply for a refund at a

later date.

Be sure to include your name and Social Security Number on all 3 pages.

1000 Red River Street

Austin, TX 78701-2698

(800) 223-8778

www.trs.texas.gov

Teacher Retirement System of Texas Page 2 of 3

Election to Participate in Optional Retirement Program and/or

Refund

TRS28 (09-16)

Name Social Security Number

Section 5 – Payment Method for Portion Not Being Rolled Over

Direct

Deposit

I elect to have the portion of my refund being paid directly to me sent electronically to the

financial institution listed below.

Name of Financial Institution _______________________________________

Account Type (must select one)

Checking Savings

Bank Routing Number

Account Number _______________________________________

The following declaration MUST be completed if you are requesting direct deposit.

Will this payment be transferred or forwarded outside of the United States?

No Yes If yes, to what country? __________________________

Percentage to be transferred _________________%

Check I elect to have the portion of my refund paid directly to me sent to my mailing address as a

paper treasury warrant.

Section 6 - Member Certification and Signature

I acknowledge that I have received a copy of the Information Sheet for ORP Election and/or Refund (TRS 28IN) and the

Special Tax Notice Regarding Your Rollover Options Under TRS, and that I have 30 days from receipt of the notice to

consider my decision of whether to elect a direct rollover of my distribution of accumulated contributions. I understand

that once I have made an election to roll over my refund and TRS has issued the distribution, my rollover is irrevocable

and cannot be changed.

Signature of Member or Retiree Date

STATE OF COUNTY OF

On _________________________ , _________________________________ acknowledged this document before me

(date)

(printed name of person whose signature appears above)

a notary public.

(SEAL)

Be sure to include your name and Social Security Number on all 3 pages.

1000 Red River Street

Austin, TX 78701-2698

(800) 223-8778

www.trs.texas.gov

Teacher Retirement System of Texas Page 3 of 3

Election to Participate in Optional Retirement Program

and/or Refund

TRS28 (09-16)

Name Social Security Number

Section 7 - Employer Certification

This is to certify that the above named individual is eligible and has elected to participate in the Optional

Retirement Program in lieu of membership in the Teacher Retirement System of Texas.

Name of Institution of Higher Education _____________________________________________________

TRS Reporting Entity Number ________________

Effective Date of Election __________________

Date First Eligible to Elect ORP _________________

ORP Eligibility Notification Date _________________

Report Month/Year for Final Deposit to TRS _____________

Printed Name of Reporting Official ________________________________________________________

Title of Reporting Official ________________________________________________________________

Signature of Reporting Official ____________________________________________________________

Date __________________

1000 Red River Street

Austin, TX 78701-2698

(800) 223-8778

www.trs.texas.gov

Teacher Retirement System of Texas Page 1 of 3

Information Sheet for Optional

Retirement

TRS28IN (09-16)

Optional Retirement Program (ORP) Election

• The election of ORP in lieu of membership in the Teacher Retirement System of Texas (TRS) is

irrevocable.

• If you established membership in TRS prior to your election to participate in ORP, your membership in

TRS is terminated by your election to participate in ORP.

• All accrued rights to benefits from TRS, if any, are forfeited upon the election of ORP. This includes

any benefits associated with TRS service credit you accrued prior to your election to participate in

ORP, such as service or disability retirement benefits.

• Only one Election to Participate in Optional Retirement Program and/or Refund form (TRS 28) should

be filed with TRS for ORP election purposes, as you may elect ORP only once in lieu of participation

in TRS. However, if you elect not to withdraw your TRS accumulated contributions at the time you

elect to participate in ORP, you may submit a second TRS 28 only for purposes of requesting a

refund.

• The election to participate in ORP in lieu of membership in TRS must be made within 90 days of the

date you become eligible to participate in ORP.

Refund Election

A person who is a participant in ORP may withdraw their accumulated contributions from TRS; however, you

are not required to withdraw your accumulated contributions at the time the election is made. To apply for a

refund at a later date, you must submit a second TRS 28. Please note that your account will not accrue

interest after your election to participate in ORP.

Federal Income Tax Implications

Refunded amounts that represent tax sheltered contributions are subject to a mandatory 20 percent federal

income tax withholding unless you elect to roll over all eligible amounts to another eligible retirement plan.

The amount withheld may not be sufficient to cover your income tax liability for the refund. A 10 percent early

withdrawal penalty assessed by the Internal Revenue Service (IRS) may also be applicable. All or a portion of

your refund that is eligible for rollover may be rolled over. For more information regarding amounts in your

TRS account that are eligible for rollover and types of retirement plans that are eligible to receive rolled over

amounts, see the Special Tax Notice Regarding Your Rollover Options Under the Teacher Retirement

System of Texas.

If you are a non-U.S. citizen and a non-resident alien, TRS is required to withhold 30 percent for federal

income tax unless you qualify for benefits under a U.S. tax treaty. If so, you must notify TRS of your eligibility

for reduced withholding or exemption from withholding and provide TRS with a completed IRS Form W-8BEN

(Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding) and any other required

documentation. The W8-BEN can be obtained on the IRS’ website, www.irs.gov, or from TRS upon request.

TRS recommends that you submit the completed Form W-8BEN with your TRS 28 in order to expedite the

processing of your refund.

It is your responsibility to submit the proper tax returns to the IRS and to pay any additional taxes or penalties

that may be due. TRS encourages you to contact your professional tax advisor for specific advice on how this

distribution may affect your taxes.

1000 Red River Street

Austin, TX 78701-2698

(512) 542-6400 (800) 223-8778

www.trs.texas.gov

Teacher Retirement System of Texas Page 2 of 3

Information Sheet for Optional Retirement

TRS28IN (09-16)

Additional Information about Rollovers

If you elect either a full or partial rollover, TRS will make the treasury warrant for the rollover payable to the

trustee of the eligible retirement plan named on the Refund Rollover Election form (TRS 6A). TRS will mail

the treasury warrant for the rollover to the address listed on your TRS 28. You are responsible for

forwarding the treasury warrant to the plan receiving the rollover in order to complete the rollover.

If the amount you elect to roll over is less than the total amount in your account at the time of distribution,

TRS will pay any balance to you through a second payment, which will be payable to you and issued as

either a direct deposit or paper treasury warrant.

If the amount you elect to roll over is less than your account total, TRS will roll over your tax sheltered funds

first, then your non-tax sheltered funds to reach the total dollar amount you chose to roll over. If the amount

you wish to roll over is less than your tax sheltered amount, TRS will pay you the remaining tax sheltered

amount minus 20% for federal income tax withholding, plus any non-tax sheltered amount in your account.

Roth IRAs: A rollover to a Roth IRA results in a taxable distribution in the year in which it is paid by TRS. If

you choose to rollover to a Roth IRA, you must complete Section 3 of the TRS 6A regarding your

withholding preference. TRS recommends that you consult with a professional tax advisor about whether

the tax sheltered amount of your refund is subject to the 10% additional tax on early distributions described

in the Special Tax Notice Regarding Your Rollover Options Under the Teacher Retirement System of Texas.

Foreign Trusts: A direct rollover may be made to a foreign trust that is part of a stock bonus, pension, or

profit sharing plan established outside the U.S., if the receiving foreign trust would qualify for exemption

from tax under Internal Revenue Code (IRC) §§ 401(a) and 501(a), except for the fact that it is a trust

created or organized outside the U.S. To claim this exemption, in addition to any other information required

by TRS, the distributee must furnish a written statement by an authorized official of the foreign trust stating

that the foreign trust is a trust described under IRC § 402(d). TRS will not make a transfer to a foreign trust

without this statement.

Tax Statements Sent by TRS

Tax statements (Form 1099-R) are required to be mailed to your address on record no later than January 31

of the year following a refund. Form 1099-R includes the total amount of the lump sum distribution, any

portion that is taxable income for the year paid, and the amount of income tax withheld. This information is

also provided to the IRS as required by federal law. If you are a non-U.S. citizen and non-resident alien,

TRS will report your distribution on a Form 1042-S instead of on a Form 1099-R.

If you elect to roll over all or a part of your refund, you will receive a separate Form 1099-R regarding the

rollover amount. Tax statements are mailed to the same address used for refunds. You must notify TRS in

writing if your address changes after you receive your refund. TRS must receive your notification prior to

December 10 of the year in which you received your refund in order to ensure that the form will be sent to

the correct address.

1000 Red River Street

Austin, TX 78701-2698

(800) 223-8778

www.trs.texas.gov

Teacher Retirement System of Texas Page 3 of 3

Election to Participate in Optional Retirement Program

and/or Refund

TRS28 (09-16)

Instructions

If you are electing ORP participation and requesting a refund of your TRS accumulated contributions:

1. Read the Special Tax Notice Regarding Your Rollover Options Under The Teacher Retirement

System of Texas.

2. Complete the Election to Participate in Optional Retirement Program and/or Refund form (TRS 28) in

its entirety.

3. Section 4 – Refund Election. You must select one of the three options: Refund, Direct Rollover, or No

Refund.

4. Section 5 – Payment Method for Portion Not Being Rolled Over. You may select either Direct Deposit

or a paper treasury warrant. If you select Direct Deposit, be sure to include your financial institution

name, account type, bank routing number, account number, and complete the declaration.

5. Sign the form in the presence of a notary public in Section 6 – Member Certification and Signature.

6. Have your employer complete Section 7 – Employer Certification.

7. Send the completed form to TRS.

If you previously elected ORP participation but you did not withdraw your TRS accumulated contributions at

the time you elected ORP and you are now applying for a refund of your TRS accumulated contributions:

1. Read the Special Tax Notice Regarding Your Rollover Options Under The Teacher Retirement

System of Texas.

2. Complete Section 1 – Member Information on the Election to Participate in Optional Retirement

Program and/or Refund form (TRS 28).

3. Do Not Complete Section 2 – Prior Optional Retirement Program Election Information.

4. Do Not Complete Section 3 – Member Election.

5. Complete Section 4 – Refund Election. You must select one of the three options: Refund, Direct

Rollover, or No Refund.

6. Complete Section 5 – Payment Method for Portion Not Being Rolled Over. You may select either

Direct Deposit or Check. If you select Direct Deposit, be sure to include your financial institution name,

account type, bank routing number, account number, and complete the declaration.

7. Sign the form in the presence of a notary public in Section 6 – Member Certification and Signature.

8. Do not have your employer complete Section 7 – Employer Certification.

9. Send the completed form to TRS.

Important Information

The form must be signed in front of a notary. If your name on the TRS 28 is different than the one shown on TRS

records, you must send TRS a copy of the court order or marriage license documenting your name change. If your

attorney-in-fact signs the request, a copy of the power of attorney must be submitted for review.

Please note that in some cases, TRS will issue your refund payment as a paper treasury warrant even when you have

selected direct deposit. This may occur if the direct deposit information was not completed in its entirety. In addition, if

you elect direct deposit and indicate that 100% of the refund will be transferred out of the United States, you will not be

able to receive your refund through direct deposit and TRS will issue your refund payment as a paper treasury warrant

mailed to the address listed on your TRS 28 form.

If you would like to roll over all or a portion of your accumulated contributions that are eligible for rollover, a Refund

Rollover Election form (TRS 6A) must be submitted to our office. You must complete and sign the form TRS 6A

indicating the amount that you wish to roll over. The representative of the retirement plan (plan administrator or trustee)

accepting the rollover must also sign the form certifying that the plan is eligible to receive the funds being rolled over

from your TRS account. Refer to the Special Tax Notice Regarding Your Rollover Options Under the Teacher

Retirement System of Texas included with the Requesting a Refund packet for additional information as you consider

whether to roll over your refund.

02 2018

Cisco College

Optional Retirement/Tax Sheltered Annuities

Approved Program Carriers

Contact Information

New Accounts:

 VALIC

Representative: Landon Freeman

https://www.valic.com

682-557-9384

 Lincoln Financial Group

Representative: Lawrence Smith

https://www.lfg.com

www.elsvisionwealth.com

(469) 271-1318

 VOYA Financial Services (formerly ING/Aetna)

Representative: Zera Harris

www.voya.com

(972) 225-1524

 ISC Group, Inc.

Representative: Frank Wilson

www.iscgroup.com

(940) 781-6053 cell

NOTICE TO NEW EMPLOYEES

You may elect to retain your common law right of action if, no

later than five days after you being employment or within five

days after receiving written notice from the employer that the

employer has obtained workers’ compensation insurance

coverage, you notify your employer in writing that you wish to

retain your common law right to recover damages for personal

injury. If you elect to retain your common law right of action,

you cannot obtain workers compensation income or medical

benefits if you are injured.

NOTICE TO EMPLOYEES CONCERNING

WORKERS’ COMPENSATION IN TEXAS

COVERAGE: [Name of employer]

has workers’ compensation insurance coverage from [name of commercial insurance company]

in the event of

work-related injury or occupational disease. This coverage is effective from [effective date of workers’

compensation insurance policy] . Any injuries or occupational diseases which occur on or after

that date will be handled by [name of commercial insurance company]

. An employee or a person acting on the employee’s behalf,

must notify the employer of an injury or occupational disease not later than the 30th day after the date

on which the injury occurs or the date the employee knew or should have known of an occupational

disease, unless the Texas Department of Insurance, Division of Workers’ Compensation (Division)

determines that good cause existed for failure to provide timely notice. Your employer is required

to provide you with coverage information, in writing, when you are hired or whenever the employer

becomes, or ceases to be, covered by workers’ compensation insurance.

EMPLOYEE ASSISTANCE: The Division provides free information about how to le a workers’

compensation claim. Division staff will answer any questions you may have about workers’

compensation and process any requests for dispute resolution of a claim. You can obtain this assistance

by contacting your local Division eld ofce or by calling 1-800-252-7031. The Ofce of Injured

Employee Counsel (OIEC) also provides free assistance to injured employees and will explain your

rights and responsibilities under the Workers’ Compensation Act. You can obtain OIEC’s assistance

by contacting an OIEC customer service representative in your local Division eld ofce or by calling

1-866-EZE-OIEC (1-866-393-6432).

SAFETY VIOLATIONS HOTLINE: The Division has a 24 hour toll-free telephone number for

reporting unsafe conditions in the workplace that may violate occupational health and safety laws.

Employers are prohibited by law from suspending, terminating, or discriminating against any employee

because he or she in good faith reports an alleged occupational health or safety violation. Contact the

Division at 1-800-452-9595.

Notice 6 (01/13) TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS’ COMPENSATION Rule 110.101(e)(1)

Claims Administrative Services

CISCO COLLEGE

Claims Administrative Services

COVERED EMPLOYER

Texas Workers’ Compensation Rule 110.101(e)(1) requires employers who are covered by workers’

compensation through a commercial insurance company to advise their employees that they do have

workers’ compensation insurance coverage and to advise their employees of the Texas Department

of Insurance, Division of Workers’ Compensation's toll free number to obtain additional information

about their workers' compensation rights.

Notices in English, Spanish and any other language common to the employer's emplo

must be posted and:

Prominently displayed in the employer's personnel ofce, if any;

Located about the workplace in such a way that each employee is likely to see th

regular basis;

Printed with a title in at least 26 point bold type, subject in at least 18 point bold ty

at least 16 point normal type; and

Contain the exact words as prescribed in Rule 110.101(e)(1).

yee population

e notice

pe, and

on a

text in

The notice on the reverse side meets the above requirements. Failure to post or to provide notice

as required in the rule is a violation of the

Act and Division rules.

The violator may be subject to

administrative penalties.

Do Not Post This Side

FFICE OF INJURED EMPLOYEE COUNSEL

As an injured employee in Texas, you have the right to free assistance from the Office of Injured Employee Counsel (OIEC). OIEC is

a state agency that is responsible for assisting injured employees with their claim in the workers’ compensation system.

You can contact OIEC by calling its toll-free telephone number: 1-866-EZE-OIEC (1-866-393-6432). More information about OIEC

and its Ombudsman Program is available at the agency’s website (www.oiec.state.tx.us

MBUDSMAN PROGRAM

HAT IS AN OMBUDSMAN?

An Ombudsman is an employee of OIEC who can assist you if you have a dispute with your employer’s insurance carrier. An

Ombudsman’s assistance is free of charge. Each Ombudsman has a workers’ compensation adjuster's license and has completed a

comprehensive training program designed specifically to assist you with your dispute.

If you have a proceeding scheduled before the Texas Department of Insurance, Division of Workers’ Compensation, an Ombudsman

can:

• Help you prepare for the proceeding (Benefit Review Conference and/or C

ntested Case Hearing);

• Attend the proceeding with you and communicate on your behalf; and

• Assist you with your appeal and response to insurance carrier appeals.

TAC §276.5. Employer Notification of Ombudsman Program to Employees (03/10)

WORKERS’ COMPENSATION INSURANCE

I have read and understood the Workers’ Compensation

Insurance information provided with my new hire packet which

includes:

 Notice to new employees

 Notice to new employees concerning workers’

compensation insurance in the State of Texas

 Notification of the Ombudsman Program

Employee’s Printed Name: ____________________________

Signature of Employees: ____________________________

Date Signed: ____________________________

Employer’s Representative: ___________________________

CONTINUATION COVERAGE NOTIFICATION

(COBRA)

On April 7, 1986, a federal law was enacted (Public Law 99-272, commonly called COBRA). This law requires the State of

Texas to offer employees and dependents covered under the Texas Employees Group Benefits Program (GBP) the opportunity to

temporarily extend their health and/or dental coverage at the group rates. Continuation coverage is available only when certain

qualifying events cause coverage under the GBP to end. Coverage under COBRA is limited to the health and/or dental coverage in

effect at the time of the qualifying event.

Note: If eligible for optional coverages as a retiree, this document is only applicable to health.

WHO MAY CONTINUE COVERAGE

If you are an employee covered under the GBP, you and/or your covered dependents have the right to elect up to 18 months of

continuation coverage if your GBP coverage ended due to:

 Termination of employment for reasons other than gross misconduct (including retirement with less than 10 years of service

credit with the Employees Retirement System of Texas (ERS), Teacher Retirement System (TRS) of Texas or an Optional

Retirement Program (ORP)

 Loss of GBP eligibility due to expiration of coverage following leave without pay

 Loss of GBP eligibility due to reduction of hours

If you are a dependent covered by an employee under the GBP, you have the right to elect up to 36 months of continuation

coverage if your GBP coverage ended due to loss of dependent status, including such qualifying events as:

 Death of the employee

 Divorce of the employee and covered spouse

 A dependent child who marries or attains age 25

 An other than natural child who moves out of the employees household

If you are a former employees dependent continuing GBP coverage under COBRA as a result of the former employees termination

of employment, expiration of coverage following leave without pay or loss of GBP eligibility due to reduction of hours, you have

the right to extend your coverage for a total continuation period of up to 36 months if a secondary qualifying event occurs and you

lose dependent status under the rules of the GBP provided you were covered as a dependent at the time of the initial qualifying

event. A COBRA participants newborn child or newly adopted child acquired on or after the initial qualifying event who is added

to the existing COBRA coverage will also have a right to extend their coverage. Secondary qualifying events which occur during

the initial 18 months of continuation coverage that entitles covered dependents to the additional continuation period are:

 Death of the former employee

 Divorce of the former employee and covered spouse

 A dependent child who marries or attains age 25

 An other than natural child who moves out of the employees household

 The former employee begins receiving Medicare benefits.

ELECTION PERIOD

For employees and dependents eligible for continuation coverage

The ERS will provide you with a COBRA Election Form and COBRA Notification following the termination of your coverage.

You and/or your dependents must formally elect continuation coverage on the form provided and submit the appropriate premium

payment within 105 days of the date coverage terminated or the date of notice, whichever is later. Failure to do so will result in

the forfeiture of your continuation coverage. Each covered participant has the right to elect continuation coverage independently.

You and your dependents will not have coverage after the date coverage terminated until you formally elect continuation

coverage and pay all premiums due retroactive to the first day of the month following the date coverage terminated.

For dependents whose coverage terminates due to loss of dependent status

The member or the covered dependent has the responsibility to notify one of the following of a divorce or when a covered

dependent loses dependent status. Notification must occur within 60 days of the qualifying event date.

 Active employee  your agency or institution Benefits Coordinator

 Retiree or current COBRA participant  the Employees Retirement System of Texas (ERS)

COB Notice (R 09/2003) Page 1 of 4

Upon notification the ERS will provide a form for the dependent to complete and forward to the ERS with the appropriate

premium within 105 days of the date of notice on the form or the date coverage terminated, whichever is later. If the Benefits

Coordinator or the ERS is not notified within 60 days, continuation coverage will be forfeited.

Adding newly acquired dependents during the election period

Newly acquired dependents may be added to the COBRA continuation coverage provided the ERS is notified in writing within 30

days of the date the individual first became an eligible dependent. This rule also applies during the 105-day election period.

Example: An employee terminated employment on July 20 and acquired an eligible dependent on August 5. To add the new

dependent to the COBRA continuation coverage, the request must be postmarked on or before September 4 even though the 30-

day notification deadline occurs before the end of the 105-day election period.

COST OF CONTINUATION COVERAGE

Persons electing continuation coverage must pay the full premium plus an additional 2% administrative fee. The first premium

payment is due within 105 days from the date of the COBRA qualifying event or the date of notice, whichever is later. If you will

receive an annuity from ERS, your monthly premium will be automatically deducted from your monthly annuity payment. To

ensure that no break in coverage occurs, the first premium payment must include all premiums due retroactive to the first day of

the month following the date coverage terminated. Subsequent monthly payments are due on the first of each coverage month

and must be postmarked by the U. S. Postal Service within 30 days of the due date. If your payment is late, your coverage will

be automatically cancelled retroactive to the last day of the month in which a full payment was received and was not considered

delinquent.

LENGTH OF CONTINUATION COVERAGE

Your continuation coverage may be cancelled for any of the following reasons:

 The required premium for your continuation coverage is not received within the required time period, regardless of the

circumstances.

 You enroll in another group health plan on or after the COBRA coverage effective date unless the other group health plan

subjects you to a pre-existing condition limitation or exclusion. If you enroll in another group health plan, your COBRA

coverage will end when the new group health plan covers you and does not limit or exclude coverage for pre-existing

conditions in accordance with Public Law 104-191 (Health Insurance Portability and Accountability Act of 1996).

 You begin receiving Medicare benefits on or after the COBRA coverage effective date.

 The GBP ceases to provide coverage to any employee/retiree.

 You extend coverage due to a disability and the Social Security Administration (SSA) makes a final determination that the

disability no longer exists.

 You submit a written request to cancel coverage. Cancellations will be made effective the last day of the month in which the

U. S. Postal Service postmarks your request. Therefore, you must make the full premium payment for the month in which

you are mailing the cancellation request.

IMPORTANT: Cancelled continuation coverage cannot be reinstated.

Special provision for covered individuals who are determined to be disabled by the SSA

An 18-month continuation coverage period may be extended to a possible maximum of 29 months if a qualified beneficiary is

determined to be disabled under Title II or XVI of the Social Security Act at any time prior to or during the first 60 days of COBRA

continuation coverage. The disabled individual may be any qualified beneficiary whose coverage was continued under COBRA

due to termination of employment, expiration of coverage following leave without pay or due to reduction of hours. To be eligible

for the extension, the ERS must be notified by submitting a copy of the SSA Notice of Award letter during the initial 18 months of

COBRA continuation coverage. Coverage will be extended for an additional 11 months or until Medicare entitlement begins,

whichever occurs first. The premium for the additional months of coverage will be equal to 150% of the current cost of coverage

in the GBP. A covered individual who may be eligible for the coverage extension period due to a disability must contact the local

SSA office to begin the determination process.

Conversion to an individual policy

Within thirty (30) days after the date your COBRA continuation coverage expires, you may enroll in an individual conversion health

plan and or dental plan. Please contact your health and/or dental plan for specific information.

Questions about COBRA continuation coverage should be direct to the

Customer Benefits Division of the Employees Retirement System at

(512) 867-7711 or toll free (877) 275-4377 (outside the Austin calling area only)

COB Notice (R 09/2003) Page 2 of 4

Information for Participants Continuing Their Coverage

We have prepared some of the most commonly asked questions regarding COBRA continuation coverage. These are general

questions only. For more specific information, please contact the Customer Benefits Division of the Employees Retirement

System (ERS) directly at (512) 867-7711 or toll-free (877) 275-4377 (outside the Austin calling area). Our mailing address is

P. O. Box 13207, Austin, Texas 78711-3207.

What is COBRA?

COBRA is an acronym for Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA requires employers to offer

continuation of group health and/or dental benefits for a specified time to individuals who would otherwise lose coverage due to

certain qualifying events.

What is a Qualified Beneficiary?

An individual who is entitled to COBRA continuation coverage due to being covered under a group health and/or dental plan on the

day the qualifying event causes loss of coverage (e.g., termination of employment, divorce from the covered employee, etc.).

This also includes a COBRA participants newborn child or newly adopted child acquired who is added to the coverage on or after

the initial qualifying event.

How long can a Qualified Beneficiary keep COBRA coverage?

If a qualifying event is due to termination of employment, loss of coverage following leave without pay or reduction in hours, a

qualified beneficiary is entitled to a maximum of 18 months of continuation coverage. All other qualifying events entitle a qualified

beneficiary up to 36 months of coverage. An 18-month continuation period may be extended to 36 months if a secondary

qualifying event occurs during the initial 18-month continuation coverage period (e.g., divorce, death or loss of dependent status).

A qualified beneficiary is never entitled to more than 36 months of continuation coverage.

How long can a disabled individual remain on COBRA?

A qualified beneficiary who is determined to be disabled by the SSA under Title II or XVI before or at any time during the first 60

days of COBRA coverage may be eligible to extend coverage from 18 to a possible maximum of 29 months. The ERS must

receive a copy of the SSA Notice of Award letter prior to the end of the original 18-month continuation coverage period.

How much are the premiums?

Premiums for 18-month and 36-month qualifying events are calculated at 102% of the current group rate. The premium for

disability participants who extend their coverage beyond the initial 18 months of coverage will be calculated at 150% of the current

group rate. Premiums are recalculated every year; if the rates change, the new plan year premium amount will be effective

beginning September 1. You will be sent a new payment notice for the new plan year, after September 1. Premium amounts for

other levels of coverage may be obtained by contacting the ERS or visiting the ERS website at

www.ers.state.tx.us.

When are the premiums due?

The initial COBRA premium payment will be due within 105 days of the date coverage terminated or the date of notice whichever

is later. If you will receive an annuity from ERS, your monthly premium will be automatically deducted from your monthly

annuity payment. Subsequent premiums are due on the first day of the coverage month. Your monthly premium payment must

be postmarked within thirty (30) days of the due date or coverage will be automatically cancelled retroactive to the last day of the

month in which a full premium payment was received and was not considered delinquent. For example, your June premium

payment is due on June 1, and will be considered late if it is postmarked after June 30. If the June premium payment is late,

coverage would be terminated May 31.

Will the ERS notify me if a premium payment is not received?

It is the participants responsibility to determine if a premium payment is due. If your coverage is cancelled, you will be notified

at that time. Cancelled COBRA coverage may not be reinstated.

For what reasons can COBRA coverage be cancelled by the ERS?

COBRA coverage may be cancelled prior to the end of the continuation coverage expiration date if:

 A timely premium payment is not received.

 The GBP ceases to provide coverage to any employee/retiree.

COB Notice (R 09/2003) Page 3 of 4

 The participant becomes covered under another group health and/or dental plan on or after the COBRA coverage effective

date unless the participant is subject to a pre-existing condition limitation or exclusion in the other group health plan. COBRA

coverage

will end when the new group health plan coverage begins and there is no limitation or exclusion for pre-existing conditions

in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

 The participant begins receiving Medicare benefits on or after the COBRA coverage effective date.

 The participant extends coverage due to a disability and later begins receiving Medicare benefits or the SSA makes a final

determination that the disability no longer exists.

 A written request is received from the participant requesting cancellation of coverage. Coverage cancellations will be made

effective the last day of the month in which the U. S. Postal Service postmarks the request. A full premium payment must be

submitted for the month in which a request for cancellation is submitted.

IMPORTANT: Cancelled COBRA coverage may not be reinstated

What if I become covered under another group health plan or begin receiving Medicare benefits?

You are responsible for notifying the ERS in writing when you enroll in another group health and/or dental plan or begin receiving

Medicare benefits. The right to continue COBRA coverage terminates when an individual becomes covered on or after the

COBRA effective date by another group health plan that does not limit or exclude coverage for pre-existing conditions OR if you

begin receiving Medicare benefits. Your COBRA coverage will be cancelled retroactive to the last day of the month prior to the

month in which you first became covered under the other group health and/or dental plan or began receiving Medicare benefits.

Under HIPAA, a group health plans pre-existing condition exclusion period will be reduced month for month by the individuals

preceding period of creditable coverage under another health plan. The continuous coverage period in another health plan is

considered creditable coverage provided there has been no lapse in coverage of more than 63 days. COBRA continuation

coverage may be terminated if a COBRA participant becomes covered by a new group health plan with a pre-existing condition

exclusion clause that is satisfied by the creditable coverage provision. The HIPAA rules limiting the applicability of exclusions

in most employers health plans for pre-existing conditions became effective in plan years beginning on or after July 1, 1997.

If a participant becomes covered by another group health plan that limits or excludes coverage for pre-existing conditions on or

after the COBRA effective date, COBRA coverage will not be terminated until the expiration of the pre-existing conditions exclusion

period. In order to continue COBRA coverage you will be required to provide the following items regarding the other group health

plan: documentation of the pre-existing conditions limitation provision, documentation of the effective date of coverage for each

person that is covered by the other group health plan and documentation (e.g. medical or prescription billings) indicating that

services were provided during the pre-existing period for each person that is covered by the other group health plan. COBRA

coverage will be cancelled on the last day of the month in which the pre-existing condition exclusion period expires.

What if I return to employment with a GBP participating agency or higher education institution?

If you return to employment with a GBP participating agency or higher education institution while your COBRA coverage is in

effect, your COBRA coverage will extend through the end of your rehire month. The full COBRA premium for the month during

which you became covered as an active employee or as a dependent of an active employee will be due. This will not result in a

break in coverage. However, if the full premium is not received, COBRA coverage will be retroactively cancelled and you will be

subject to the 90-day waiting period.

May I change my health and/or dental carrier or make changes to my COBRA coverage?

COBRA coverage will continue with your current health and/or dental carrier. If you are enrolled in a Health Maintenance

Organization (HMO) and move out of the service area where there is no other HMO available, you will be automatically enrolled

in HealthSelect. You may decrease your level of coverage by submitting a written request to the ERS. The decrease in coverage

will be effective the first day of the month following the postmarked date of your request. Newly acquired dependents may be

added if you notify the ERS in writing within thirty (30) days of the qualifying life event. (For example, if you were married on

July 1, to add your new spouse, your request must be postmarked on or before July 31). Other eligible dependents may be added

and eligible changes may be made during the annual Summer Enrollment Period or through the Evidence of Insurability (EOI)

process.

Can COBRA coverage be converted to an individual policy?

COBRA coverage may be converted to an individual policy if you apply for conversion within thirty (30) days after the date your

COBRA coverage expires or is cancelled, provided your premium payments are current. We will notify you forty-five (45) days

before the expiration date. Please contact your health and/or dental carrier for specific information about conversion.

COB Notice (R 09/2003) Page 4 of 4

COBRA

This is to certify that I have received a

CONTINUATION COVERAGE NOTIFICATION (COBRA) FORM.

___________________________

Signature of Employee

_________________

__________

Date

THE EMPLOYEES RETIREMENT SYSTEM OF TEXAS

SUMMARY NOTICE OF PRIVACY PRACTICES

The Em

ployees Retirement System of Texas (“ERS”) administers the Texas Employees Group Benefits Program,

including your health plan, pursuant to Texas law. THIS NOTICE DESCRIBES HOW ERS MAY USE OR DISCLOSE

MEDICAL INFORMATION ABOUT YOU AND HOW YOU CAN GET ACCESS TO YOUR OWN INFORMATION

PURSUANT TO THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (“HIPAA”)

PRIVACY RULE. PLEASE REVIEW THIS NOTICE CAREFULLY.

Uses and disclosures of health information:

ERS and/or a third-party administrator under contract with ERS may use health information about you on behalf of your

health plan to authorize treatment, to pay for treatment, and for other allowable health care purposes. Health care

providers submit claims for payment for treatment that may be covered by the group health plan. Part of payment includes

ascertaining the medical necessity of the treatment and the details of the treatment or service to determine if the group

health plan is obligated to pay. Information may be shared by paper mail, electronic mail, fax, or other methods.

By l

aw, ERS may use or disclose identifiable health information about you without your authorization for several reasons,

including, subject to certain requirements, for public health purposes, for auditing purposes, for research studies, and for

emergencies. ERS provides information when otherwise required by law, such as for law enforcement in specific

circumstances. In any other situation, ERS will ask for your written authorization before using or disclosing any identifiable

health information about you. If you choose to sign an authorization to disclose information, you can later revoke that

authorization to stop any future uses and disclosures. ERS cannot use or disclose your genetic information for

underwriting purposes. ERS may change its policies at any time. When ERS makes a significant change in its policies,

ERS will change its notice and post the new notice on the ERS website at www.ers.state.tx.us. Our full notice is available

For more information about our privacy practices, contact the ERS Privacy Officer. ERS originally adopted its Notice of

Privacy Practices and HIPAA Privacy Policies and Procedures Document April 14, 2003, and subsequently revised them

effective February 17, 2010, and September 23, 2013.

Individual rights:

In most cases, you have the right to look at or get a paper or electronic copy of health information about you that ERS

uses to make decisions about you. If you request copies, we will charge you the normal copy fees that reflect the actual

costs of producing the copies including such items as labor and materials. For all authorized or by law requests made by

others, the requestor will be charged for production of medical records per ERS’ schedule of charges. You also have the

right to receive a list of instances when we have disclosed health information about you for reasons other than treatment,

payment, healthcare operations, related administrative purposes, and when you explicitly authorized it. If you believe that

information in your record is incorrect or if important information is missing, you have the right to request that ERS correct

the existing information or add the missing information. You have the right to request that ERS restrict the use and

disclosure of your health information above what is required by law. If ERS accepts your request for restricted use and

disclosure then ERS must abide by the request and may only reverse its position after you have been appropriately

notified. You have the right to request an alternative means of communications with ERS. You are not required to explain

why you want the alternative means of communication.

Complaints:

If you are concerned that ERS has violated your privacy rights, or you disagree with a decision ERS has made about

access to your records, you may contact the ERS Privacy Officer. You also may send a written complaint to the U.S.

Department of Health and Human Services. The ERS Privacy Officer can provide you with the appropriate address upon

request.

Our Legal duty:

ERS is required by law to protect the privacy of your information, provide this notice about our information practices, follow

the information practices that are described in this Notice, and obtain your acknowledgement of receipt of this Notice.

Detailed Notice of Privacy Practices:

For further details about your rights and the federal Privacy Rule, refer to the detailed statement of this Notice. You can

ask for a written copy of the detailed Notice by contacting the Office of the Privacy Officer or by visiting ERS’ web site at

www.ers.state.tx.us. If you have any questions or complaints, please contact the ERS Privacy Officer by calling (512) 867-

7711 or toll-free (877) 275-4377 or by writing to ERS Privacy Officer, The Employees Retirement System of Texas, P.O.

Box 13207, Austin, TX 78711-3207.

_____________________________________________________ __________________________________

Signature Date

EEO Training Instructions

All Cisco College employees (full-time/part-time) are required by law to complete the Equal

Employment Opportunity Training upon initial employment and every two years thereafter. An

updated Computer Based Training (CBT) has been made available to us by the Texas Workforce

Commission. Please be prompt about completing this required training. Upon completion please

send a copy of your certificate to the HR Office

. Your EEO training completion date is tracked in your

Payroll System Record, and a copy is filed in your personnel file.

u will be reminded via email four weeks prior to your 2-year completion date so you will have

sufficient time to take the course again and submit your new Completion Certificate by the 2-year

mark from your previous training.

To Take the EEO Training

1. Ensure your computer has Adobe Flash loaded.

2. You may select the link below:

https://www.softchalkcloud.com/lesson/serve/XAU6OjCIblu1z5/html

3. Go to the Cisco College website (www.cisco.edu).

• Select “Faculty & Staff” link

• Under “Human Resources,” select “EEO Training” link

• You will be at the Login Prompt for the EEO Training Course.

4. Login Information is as follows:

• You will be prompted to enter your work email address

• This will take you directly into the course

5. You can stop the course to go back to finish it at a later date. However, you cannot start the

course over again or change previously completed answers. The course will simply pick up at

the point you stopped.

6. When you are prompted at the end of the course to enter your “Agency Code,” you should

enter “Cisco College & Your name,” (EX: Cisco College - Pam Page). This information will be

used for your completion certificate. Select “Print Certificate.” Once printed, then select

“Finish.” HR MUST HAVE A COPY OF YOUR CERTIFICATE IN ORDER TO GIVE YOU CREDIT

FOR COMPLETING THE COURSE.

7. IMPORTANT INFO ONLY IF YOU ARE UNABLE TO PRINT A CERTIFICATE: If you are unable to print a

certificate (very rare occurrence), be sure to write down the “Completion Number,” and email it to

the HR Office. You must have the Completion Number in order to prove successful completion of the

course to request a printed certificate. HR must receive a copy of the certificate to credit you with

completion of the course.

July 2014

EEO Training Acknowledgment

I have received notification from Human Resources of the requirement to complete EEO Training as a

new employee of Cisco College. I understand that within 30 days of employment, I must complete

the training, print a certificate, and provide a copy of the completion certificate to the Human

Resources Office. I understand that I will have to re-certify this training every two years, if still

employed with Cisco College. I also understand that the link to take the course may be accessed by

me as indicated below:

• You may select the link below:

https://www.softchalkcloud.com/lesson/serve/XAU6OjCIblu1z5/html

• Go to the Cisco College website (www.cisco.edu).

• Select “Faculty & Staff” link

• Under “Human Resources,” select “EEO Training” link

• You will be at the Login Prompt for the EEO Training Course.

I have a

lso been provided a copy of the EEO Training Instructions to assist me in completing the

training.

__________________

____________________ ________________________________

Name Date

July 2014

Acknowledgement o

f Official Transcripts

Requirement

Asanewly‐hiredemployeewithCiscoCollege,Iunderstandthatitismyresponsibilitytoorderand

haveofficialtranscriptssentdirectlytothefollowingaddress:

ShelliGarrett

DirectorofHumanResources

101CollegeHeights

Cisco,Texas76437

ThisisaSACSrequirementandnecessarytomaintainourcredentialing.Ifurtherunderstandtha

t

HumanResourcesofficemustreceiveandhaveonfileofficialtranscriptsforallmydegreeswithin30

daysofmyhiredate.

TheHROfficewillconfirmreceiptofthesetranscriptstomeviamyCiscoCollegeemailaddress.

_________________________________________________ ______________________________

SignedDate

Veteran Status

The following request for information is used for reporting purposes and to obtain

information for the Veteran Workforce Summary Report. The Veteran Workforce Summary

Report compiles and analyzes information on the hiring and employment of veterans by

Texas state agencies and institutions of higher education, including public community and

junior colleges.

___ I am not a Veteran ___ Disabled Veteran ___ I am a Veteran

Are you an orphan of a veteran, if veteran was killed while on active duty? YES NO

Are you a surviving spouse of a veteran (who has not remarried)? YES NO

Employee Signature __________________________ Date______________

The next section of pages (39-47) are your

ERS benefit selection forms. Please fill in

ONLY demographic information and hold

until you are scheduled with Human

Resources for the New Employee

Orientation to review benefit selections.

If you are covering any dependent

children, please complete a certification

form for each child.

BENEFITS ELECTION FORM

Information provided to ERS is maintained for managing your benefits.

If you have questions about your information, or believe that information provided to ERS may be incorrect, please notify

your Benefits Coordinator or HHS Employee Service Center.

SECTION A: EMPLOYEE DATA (To be completed by employee.)

Social Security Number/National ID (SSN) Employee ID First Active Duty Date

Employee Name: First, MI, Last Eligibility County

Mailing Address o Check if new

City State ZIP Code Phone Number

o Home o Cell ( )

Email Address Gender Date of Birth

o M o F

Agency Name Dept ID/Agency Number Employee Class Insurance Pay Rate

Employee SSN/National ID Correction Employee Name Change or Correction Date of Birth Correction

Please provide this information, as it could affect the waiting period for your medical insurance.

• Were you covered as a dependent under the Texas Employees Group Benefits Program (GBP) at the time of your hire? o Yes o No

If yes, please provide the Social Security number of the person covering you: _________________________________________________

• Are you a University of Texas (UT) or Texas A&M University (TAMU) employee or dependent transferring to this GBP-participating agency or

institution without a break in health coverage? o Yes o No Date coverage ends ____________

If yes, please provide proof of no break in coverage to your benefits coordinator. If you are a Health and Human Services (HHS) Enterprise

employee, provide the proof to HHS Employee Service Center.

• Are you recently rehired with the same state agency within 90 days of leaving active military duty? o Yes o No

If yes, please provide your military release date: _______________.

SECTION B: ACTION (Mark appropriate choice.)

DTA o FTE to PTE/PTE to FTE OR Retiree RTW/Retiree LTW FSC o Family Status Change HIR o New Hire

LOA o Leave of Absence PHC o Post Hire Change RED o Reduction while on LOA REH o Rehire RFL o Return from Leave

SECTION C: REASON CODE (See Family Status Change reference table on page 4 before completing.)

Complete for changes during the plan year. Reason Code: _________ Event Date: ________________ (mm-dd-yyyy)

Continue to next page to complete form.

You may complete your benets election either by:

• Using your online account at www.ers.texas.gov, or

• Sending this completed form to your benets coordinator or HHS

Employee Service Center for employees at HHS Enterprise agencies

ERS GI-1.180 (R 5/2019) (Page 1 of 4)

ERS GI-1.180 (R 5/2019) (Page 2 of 4)

SECTION E: DEPENDENT PERSONAL DATA (and coverage choices.)

Dependent Tobacco-user Certification: If your dependents are enrolled in a GBP health plan, you must certify below if your dependent used

any type of tobacco product five or more times in the last three months. This includes but is not limited to cigarettes, pipes, cigars, cigarillos,

snuff or chewing tobacco products.

Dependent

Relationship*

Dependent’s Name

(First, MI, Last)

Gender

Date of Birth

(mm-dd-yyyy)

Dependent SSN

(Required for 12 months or older)

Health Dental Vision Dep. Life

Tobacco

User

o Sp o D

o S o O

o M

o F

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Sp o D

o S o O

o M

o F

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Sp o D

o S o O

o M

o F

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Y

o No

o Sp o D

o S o O

o M

o F

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Sp o D

o S o O

o M

o F

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

o Yes

o No

* Relationship Code: Sp – Spouse D or S - Natural or adopted daughter or son O – Other than natural or adopted child. Includes stepchild,

foster child, or ward child.

If you are adding a child, you must complete a Dependent Child Certification form (ERS GI 1.081) available at www.ers.texas.gov or by calling

ERS. For dependents newly enrolled in health coverage, you will be required to provide documentation to verify your dependents’ eligibility.

Did your dependent have GBP coverage under ERS through another member within the last 31 days? o Yes o No

If yes, please provide the Social Security number under which your dependent was covered: _________________________________

Is this dependent a new addition to your household because of this event? Please check one only:

o Adoption o Acquisition of other than natural child o Birth o Not newly acquired o Marriage

SSN _______________________________ Employee Name: First, MI, Last ________________________________________________

Employee Tobacco-User Certification: If you are enrolling in the GBP health plan, have you used any type of tobacco product five or more

times in the last three months? This includes but is not limited to cigarettes, pipes, cigars, cigarillos, snuff or chewing tobacco products.

o Yes o No

SECTION D: BENEFITS OPTIONS (Mark appropriate choices.)

Health Coverage

Optional Benets (Newly hired employees may elect benets on rst active duty date or

within 31 days of hire/rehire without enrolling in health coverage.)

Effective date, if different from hire/rehire date ______________________ (mm-dd-yyyy)

Health Dental* Vision

Optional Term Life

Insurance**

Voluntary

AD&D*

Dependent Term

Life Insurance**

Short-term

Disability**

o Waive

o HealthSelect of Texas

o Consumer Directed

HealthSelect

o HMO Name

_____________________

o Enroll/Add/Drop

Dependent

(See Section E)

o Waive + Opt-Out Credit*

(By checking Waive + Opt

Out Credit, you also certify

that you have comparable

coverage. See page 3 for

important information.)

o Waive

o State of Texas

Dental Choice

Plan

o DeltaCare USA

DHMO

o Enroll/Add/Drop

Dependent

(See Section E)

Waive

o State of Texas

Vision

o Enroll/

Add/Drop

Dependent

(See Section E)

o Waive

o Enroll

Elect coverage level

o OL1 Election 1

o OL2 Election 2

o OL3 Election 3

o OL4 Election 4

Decrease Level to

o OL1 Election 1

o OL2 Election 2

o OL3 Election 3

Waive

o You Only

o You + Family

$__________

Amount up to

$200,000 in

increments of

$5,000

o Waive

o Enroll/Add/

Drop Dependent

(See Section E)

o Waive

o Enroll

Long-term

Disability**

o Waive

o Enroll

If you want to elect a TexFlex health, dependent care, or limited account as a new enrollee or due to a

qualifying life event, you must complete the TexFlex Enrollment Change Form.

*A monthly credit of up to $60 (or $30 for part-time participants) can be applied to optional coverage (dental, vision and AD&D).

**To add this coverage will require evidence of insurability (EOI). Initiate the EOI process online by signing into your online account at

www.ers.texas.gov, or contact your benefits coordinator/HHS Employee Service Center.

Continue to next page to complete form.

ERS GI-1.180 (R 5/2019) (Page 3 of 4)

SECTION F: AUTHORIZATION (Carefully read the statements below before you sign and date.)

I authorize payroll deductions for the elections indicated on this Benefits Election Form. I understand that my insurance coverage may

be cancelled if I do not pay the required amounts due, either by payroll deduction or personal payment. I understand that all insurance

premiums are deducted on a pre-tax basis, except Dependent Life, State of Texas Dental Discount Plan, and Disability. I authorize any

provider to release any information on persons covered when needed to verify eligibility or to process an insurance claim/complaint. I

understand that insurance participation rules and enrollment and benefits information are available from my benefits coordinator/HHS

Employee Service Center or ERS. I understand that double coverage for dependents is not allowed for health, vision and dental

coverage in the Texas Employees Group Benefits Program (GBP). I understand that state law does not permit me to receive more

than one state insurance contribution as either an employee, retiree, or dependent. I certify that I am familiar with the requirements

for enrolling myself and/or dependent(s) in the GBP based on a new/post hire change or a qualifying life event (QLE). I further certify that

my QLE is valid, correct, and allowable under the GBP. I understand that I may be asked to show documentation to support my QLE and

will be required to submit documentation for any newly enrolled dependents, proving their eligibility. I also understand that if I knowingly

provide any materially incorrect, incomplete, untrue, information, I may be permanently expelled from the GBP and/or subject to criminal

prosecution.

Notice about Insurance: Funding for health and other insurance benefits for participants in the GBP is subject to change based on

available state funding. The Texas Legislature determines the level of funding for such benefits and has no continuing obligation to provide

funding for those benefits beyond each fiscal year.

Tobacco-User Certification: I certify my understanding and agreement to the following: “Tobacco Products” are cigarettes, cigars, pipe

tobacco, chewing tobacco, snuff, dip or any other products that contain tobacco, and a “Tobacco User” is a person who has used any

Tobacco Products five or more times within the past three consecutive months. If I (or any of my covered dependents): 1) have used

Tobacco Products as a Tobacco User; or 2) start using Tobacco Products without notifying ERS, I will be subject to monetary penalties

and may be terminated from participation in the GBP. Also, failure to notify ERS will constitute fraud. Under the penalties of perjury,

the above information is true and correct. Providing or entering false information may disqualify me from continued coverage in the

GBP. If I intentionally misrepresent material facts or engage in fraud, my coverage may be rescinded retroactively to the date of the

misrepresentation or fraudulent act. In that event, I will receive thirty days notice before my coverage is rescinded. Further, if I or any of my

covered dependents start using Tobacco Products without notifying ERS, I will be subject to monetary penalties and such failure to notify

ERS will constitute fraud.

If you certified yourself or any of your dependents as a tobacco user, you may be able to participate in Choose to Quit, an alternative to the

tobacco-user premium, if it is right for your health status and complies with your doctor’s recommendations. For more information about this

program, visit, https://ers.texas.gov/Tobacco-Policy-and-Certification.

If you previously certified yourself or any of your dependents as a tobacco user, and you or they have stopped using tobacco for three

consecutive months, you must complete the Tobacco-User Certification Form (ERS 2.933) available at https://ers.texas.gov/PDFs/Forms/

Tobacco_User_Certification_ERS2933.pdf, or change the certification using your online account at www.ers.texas.gov.

If you selected “Waive + Opt-Out Credit”: I certify that I do not want the health plan coverage offered to me as an eligible participant. I

am waiving my health plan coverage and certify that I have other health plan coverage with substantially equivalent coverage to the basic

health plan. I understand waiving my state health insurance will cancel my prescription drug coverage and $5,000 Basic Term Life policy.

I will receive a credit of up to $60 (or $30 for part-time participants) that will be applied only toward the cost of eligible optional coverage

in which I am enrolled (dental, vision and/or Voluntary Accidental Death and Dismemberment (AD&D) excludes the State of Texas Dental

Discount Plan). The credit is in place of the state contribution for basic health coverage. Due to federal legislation Medicare members

cannot receive the Opt-Out Credit. I am able to view the Health Insurance Opt-Out Credit applied toward my eligible optional coverage

premium by signing into my online account at www.ers.texas.gov.

I understand that if I am currently in a waived status, I must have a QLE or wait until Summer Enrollment to enroll in medical or

optional coverage offered to eligible participants.

Employee’s Signature ______________________________________________ Date Signed (mm-dd-yyyy) _____________________

Keep a copy of this form for your files and return the original to your benefits coordinator.

If you are a Health and Human Services (HHS) Enterprise employee, return this form to HHS Employee Service Center.

ERS GI-1.180 (R 5/2019) (Page 4 of 4)

New Employees:

• May elect health coverage at time of hire; however, this coverage

will be effective when you have satisfied your waiting period.

Employees making changes to their benets options during the

plan year:

• Use this form to indicate only the changes you want to make.

• Complete this form on or within 31 days after your qualifying life

event (QLE) (birth, marriage, etc.).

• Using the chart below, identify a reason code (required in Section

C) when changing insurance coverage.

Below are examples of qualifying life events; other similar

circumstances may also represent a qualifying life event. Remember,

rules will determine if you can enroll in or make the insurance

changes you want. You may either enter your changes using your

online account at www.ers.texas.gov or send this form to your

benefits coordinator.

If you are a Health and Human Services Enterprise employee, you

may send this form to HHS Employee Service Center. If you do not

make changes within 31 days, you may not be eligible to make the

changes you want.

Family Status Change Reference Chart

Employee Marital Status Change

Participant gets married MAR

Participant gets a divorce or an annulment DIV

Death of a spouse DOD

Dependent Status Change

Birth of a newborn child BIR

Participant adopts, fosters, or gets court-appointed guardianship,

or becomes managing conservator of a child

ADP

Participant gains or loses dependent(s) through death DOD

Dependent becomes eligible or loses eligibility for insurance coverage

(Example: Participant’s spouse is covering their child. The child lost eligibility for

the spouse’s insurance because the child does not attend school.)

DEP

Dependent is related by blood or marriage, and was previously claimed on the participant’s income tax

return, but is no longer eligible to be claimed on participants income tax return

XMO

Child gets married DGM

Employment Status Change

Participant/Dependent employment status change ESC

Dependent becomes eligible for insurance after a waiting period DWP

Address Change that Changes

Dependent Eligibility

Dependent moves out of health or dental plan service area DMV

Medicare/Medicaid/CHIP

Eligibility Change

Participant/Dependent gains Medicare/Medicaid/CHIP eligibility MDG*

Participant/Dependent loses Medicare/Medicaid/CHIP eligibility MDL*

Signicant Change in Cost/Coverage

Imposed byThird Party

Significant change in cost by day care provider SCC

Significant change in cost/coverage of dependent’s health, vision or dental plan (excluding GBP) SCC

HIPP approval or loss of eligibility SCC

Ofce of the Attorney General (OAG)

Ordered Coverage Change

(Eligibility rules apply for

these dependents)

Participant gains requirement to provide coverage for child through a National Medical Support Notice

(NMSN) issued by the Office of the Attorney General (OAG)

(Example: employee receives an NMSN to provide health coverage for his child.)

MSO

NMSN issued by the Office of the Attorney General (OAG), which requires

participant to provide coverage for child expires

(Example: employee’s NMSN to provide health coverage for his child expires and the employee is no longer

required to continue coverage for the child.)

MSD**

* DEPENDENT ENROLLMENT INFORMATION:

CHIPRA requires a 60-day QLE window to notify ERS if:

1. The dependent is not in the GBP and loses their eligibility for Medicaid or CHIP OR

2. The dependent is not in the GBP and they become eligible for premium assistance through Medicaid or HIPP,

they have 60 days to enroll in the GBP.

DROP DEPENDENT COVERAGE INFORMATION:

In other QLE instances related to Medicaid or CHIP there is the usual 30-day window to drop dependents from the GBP.

** Employees must contact their benefits coordinator (HHS Enterprise employees contact HHS Employee Service Center) to drop dependent(s)

added with a National Medical Support Notice (NMSN).

You may be asked to show proof of the QLE and will be required to submit documentation

for newly enrolled dependents, proving their eligibility.

Employees Retirement System of Texas PO Box 13207 Austin, Texas 78711-3207 (877) 275-4377 (TTY:711)

Pick one true statement to certify dependent eligibility:

___ 1. I certify this child is my:

(check one, a. through f.)

___ a. natural child,

___ b. adopted child,

___ c. foster child,

___ d. stepchild,

___ e. court-appointed ward, or

___ f. child under managing conservator.

- OR -

___ 2. I certify:

• this child is related to me by blood or

marriage AND

• was claimed as a dependent on my

federal income tax return in the previous

calendar year AND

• I will continue to claim this child on my

federal income tax return for every year

the child is enrolled.

- OR -

___ 3. I certify:

• this child is related to me by blood or marriage and was

not claimed on my federal income tax return for last

year because the child was born in the current calendar

year AND

• will be claimed on my federal income tax this year and

for every year the child is enrolled.

- OR -

___ 4. I certify this child is related to me by blood or marriage and is

eligible for benets in the Texas Employees Group Benets

Program due to good cause and I have read and understand

the denition of good cause provided below. Denition of

Good Cause: Good cause means that you cannot certify

this child under items 2 or 3 above because of unexpected

circumstances that required you to take parental responsibility

for the child this year. You may not certify the child for good

cause unless you will legally claim the child as your dependent

for federal income tax purposes in this current year.

ERS GI-1.081 (R 1/2018)

DEPENDENT CHILD CERTIFICATION

Information provided to the Employees Retirement System of Texas (ERS) is

maintained for managing your benets.

If you have questions about your information, or believe that

information provided to ERS may be incorrect, please notify ERS.

Complete a separate form for each dependent child to be covered.

Note: If you certify online, you do not need to complete this

form, unless requested due to a dependent eligibility audit.

You may certify your dependent either by:

• Using your online account at www.ers.texas.gov, or

• Active employees: may send this completed form to your

benets coordinator or HHS Employee Service Center, or

• Other members: may send this completed form to:

Employees Retirement System of Texas

Customer Benets

P.O. Box 13207

Austin, TX 78711-3207

(866) 399-6908 Toll-free

SECTION A: PERSONAL DATA

Employee/Retiree Name: First, MI, Last Social Security Number (SSN) Employee ID

Agency Name Dept ID/Agency Number

Legal Name of Child: First, MI, Last

Child’s Social Security Number

(Required for 12 months or older)

Child’s Birth Date

mm/dd/yyyy

SECTION B: DEPENDENT CHILD CATEGORY

SECTION C: CERTIFICATION

I understand I may be asked to show documentation to support my selection. False information could lead to expulsion from the

Texas Employees Group Benets Program and/or criminal prosecution.

_______________________________________________ _________________________

Signature of Employee/Retiree Date Signed (mm-dd-yyyy)

Member Comment – Only complete this box if you choose Option 4.

TEXAS EMPLOYEES GROUP BENEFITS PROGRAM (GBP)

SUPPLEMENTAL INFORMATION FORM FOR EMPLOYEES

Information provided to Employees Retirement System of Texas (ERS)

is maintained for managing your benets.

Please mail the completed form to your health plan carrier.

SIGN, DATE AND MAIL THIS FORM TO YOUR HEALTH PLAN.

ERS GI-1.207 (R 7/2017) Over

SECTION D: PRIMARY CARE PHYSICIAN SELECTION (for HealthSelect

of Texas and Community First participants)

Name of your Health Plan:

If you’re in HealthSelect of Texas or Community First Health Plans, select your primary care physician (PCP) from the plan’s provider

directory. Attach an additional sheet if necessary.

Patient’s Name:

First, MI, Last

Social Security

Number (SSN)

Gender

Birthdate

(mm-dd-yyyy)

PCP Name:

First, MI, Last

PCP Address

NPI or

PCP No.

Existing

Patient?

Employee

o M

o F

o Yes

o No

Spouse

o M

o F

o Yes

o No

Child

o M

o F

o Yes

o No

Child

o M

o F

o Yes

o No

Child

o M

o F

o Yes

o No

Child

o M

o F

o Yes

o No

SECTION A: EMPLOYEE DATA

New Employee?

Yes o No

Employee Name: First, MI, Last

Birthdate

(mm-dd-yyyy)

Last four digits of

Social Security Number

Phone Number

o Home o Cell

XXX-XX-

Mailing Address City State ZIP Code Eligibility County

SECTION B: OTHER INSURANCE DATA

Please check type

of coverage:

o Employer Group Health o Employer Group Dental o Individual Health o Individual Dental

Name of Policyholder ID number

Birthdate

(mm-dd-yyyy)

Gender Relationship

o M o F o Self o Spouse o Child

Name and Address of Other

Insurance Company, TPA, HMO

Group or Policy

Effective Date _____/_____/_____

Will Coverage Continue

o Yes o No

If No, Expected Cancel Date

____/____/_____

Level of Coverage

o You Only

o You/Spouse

o You/Child(ren)

o You/Family

SECTION C: MEDICARE COVERAGE INFORMATION

Name of Medicare Beneciary Medicare Part A (Hospital) Effective Date

_____/_____/_____

Medicare Part B (Medical) Effective Date

_____/_____/_____

Medicare No. (From Medicare Card)

GENERAL INSTRUCTIONS

This GBP Supplemental Information Form is NOT an enrollment form. Enrollment forms are submitted to ERS and coverage is reported to

the selected health plan. This form will facilitate the receipt of your health care identication card once your enrollment form has successfully

been processed by ERS and your coverage reported to the selected health plan.

This GBP Supplemental Information Form must be completed, signed and dated by you when:

1) enrolling in any GBP health plan, 2) adding a dependent to your current health coverage, or 3) making an eligible health plan change (for

example, at Summer Enrollment).

SECTION A: EMPLOYEE DATA

Complete this section and specify your mailing address, ZIP Code, and Eligibility County. Indicate if you are a new employee.

SECTION B: OTHER INSURANCE DATA

Complete this section if you or any member of your family are covered by other health or dental coverage. If more space is needed, please

attach a separate sheet.

SECTION C: MEDICARE COVERAGE INFORMATION

Complete this section if you or any member of your family are covered under Medicare Part A and/or Part B. If more space is needed, please

attach a separate sheet.

SECTION D: PRIMARY CARE PHYSICIAN SELECTION

Complete this section if you are enrolling in a GBP health plan requiring a PCP selection prior to receiving services. Refer to the provider

directories at www.ers.texas.gov when completing this section.

1. Write the name of your chosen health plan.

2. Write the full name and provider code of your chosen PCP for yourself and each covered dependent, even if you are selecting the same

physician for all covered persons.

3. Indicate if you are an existing patient or not (Y/N).

If you need assistance in completing this section, contact your health plan.

SECTION E: OTHER DEPENDENT INFORMATION

1. Complete this section if you are enrolling in HealthSelect (In-Area) and your eligible dependent lives out-of-area or in another

HealthSelect network area.

2. Complete this section if you are enrolling in an HMO and your eligible dependent lives in another Texas service area of the selected HMO.

HEALTH PLAN ADDRESSES AND TELEPHONE NUMBERS:

HealthSelect

of Texas

BlueCross BlueShield

(800) 252-8039

Mail Supplemental

Information Forms to:

4002 Loop 322

Abilene, TX 79602-7330

HMO:

Community First

Health Plans, Inc.

(877) 698-7032

(210) 358-6262

Mail Supplemental

Information Forms to:

Community First

12238 Silicon Drive,

Suite 100

San Antonio, TX 78249

Scott & White

Health Plan

1206 West Campus Drive

Temple, TX 76508

Temple: (800) 321-7947

Georgetown: (800) 758-3012

Waco (254) 756-8000

KelseyCare powered by

Community Health Choice

2636 South Loop West,

Suite 900

Houston, TX 77054

(713) 295-6792;

toll-free (844) 515-4877

ERS GI-1.207 (R 7/2017) [Back]

SECTION E: OTHER COVERED DEPENDENT NOT LIVING IN THE HOUSEHOLD

o Dependent Lives Out-of-Area

o Dependent Lives in Different

Network or Service Area

Dependent Name: First, MI, Last

Social Security Number

(SSN)

Birthdate

(mm-dd-yyyy)

Mailing Address City State ZIP Code County

__________________________________________________________ _______________________________

Participant’s Signature Date Signed (mm-dd-yyyy)

EMPLOYEES RETIREMENT SYSTEM OF TEXAS

TEXFLEX ENROLLMENT/CHANGE FORM

ERS FB 9.20 (R 5/2018)

Page 1 of 3

Only for participants with active employee benets.

SECTION A: EMPLOYEE DATA

Employee Name: SSN ERS Employee ID

Type of employee: o 9-month (higher education institutions) o 12-month

SECTION B: ACTION AND REASON CODE (Check only one box.)

FSC o Family Status Change HIR o New Hire REH o Rehire PHC o Post Hire Change LOA o Leave of Absence

RED o Reduction while on LOA RFL o Return from Leave

Enter a reason code and event date if you checked the FSC box above.

See the Family Status Change (FSC) Reference Chart on page 3 before completing.

Reason Code: Event Date: (mm-dd-yyyy)

You may complete your benets election either by:

• Using your online account at www.ers.texas.gov, or

• Sending this completed form to your benets

coordinator or HHS Employee Service Center for

employees at HHS Enterprise agencies

SECTION C: TEXFLEX HEALTH CARE ACCOUNT (Fill out only one of the three options in this section, if applicable.)

o TexFlex health care account – for eligible medical, vision and dental out-of-pocket costs excluding insurance premiums. Program has

a minimum annual pledge of $180 and a maximum annual pledge of $2,650 per tax year. Enrollment/change must be made within 31 days

of your employment or qualifying life event. You will receive a TexFlex debit card, at no cost, to pay for eligible expenses. There is no annual

administrative fee for the TexFlex health care account. Note: If you do not check this box, you will not be enrolled in this account.

OPTION 1: NEW ENROLLMENT (Complete only if New Hire/Rehire or Family Status Change.)

I want my monthly deduction to be (not to exceed $220 per month): $ .00

Number of months left in the plan year (September 1 – August 31): x

Annual pledge: $ .00

OPTION 2: INCREASE PLEDGE AMOUNT (Complete only if increasing pledge amount due to a Family Status Change.)

Current annual pledge amount: $ .00

Increase my annual pledge amount to: $ .00

OPTION 3: REDUCTION (Complete only if reducing pledge amount due to a Family Status Change.)

Current annual pledge amount: $ .00

Reduce my annual pledge amount to: $ .00

SECTION D: TEXFLEX DEPENDENT CARE ACCOUNT (Fill out only one of the three options in this section, if applicable.)

o TexFlex Dependent Care Account – for eligible child or adult dependent care expenses. Program has a minimum annual pledge of $180

and a maximum annual pledge of $5,000 or the lesser of your spouse’s or your annual income that is below $5,000. Enrollment/change must

be made within 31 days of your employment or qualifying life event. The TexFlex debit card is not available to pay for dependent care expenses.

There is no annual administrative fee for the TexFlex dependent care account. Note: If you do not check this box, you will not be enrolled in this

account.

OPTION 1: NEW ENROLLMENT (Complete only if New Hire/Rehire or Family Status Change.)

I want my monthly deduction to be (not to exceed $416 per month): $ .00

Number of months left in the plan year (September 1 – August 31): x

Annual pledge: $ .00

OPTION 2: INCREASE PLEDGE AMOUNT (Complete only if increasing pledge amount due to a Family Status Change.)

Current annual pledge amount: $ .00

Increase my annual pledge amount to: $ .00

OPTION 3: REDUCTION (Complete only if reducing pledge amount due to a Family Status Change.)

Current annual pledge amount: $ .00

Reduce my annual pledge amount to: $ .00

Information provided to ERS is maintained for managing your benets. If you

have questions about your information, or believe that information provided to

ERS may be incorrect, please notify ERS.

Authorization:

I understand my TexFlex health care, dependent care, and/or limited exible spending account enrollment is irrevocable for the

plan year, unless I have a qualifying life event, terminate employment or retire. I authorize payroll deductions for the amount listed

on this form.

I understand I have until August 31 to incur health care expenses for the plan year and can carry over a minimum of $25, up to $500

of my TexFlex health care account balance to the next plan year. Any amount over $500 will be forfeited.

I understand I have until August 31 to incur eligible dental or vision expenses for the plan year and can carry over a minimum of $25,

up to $500 of my TexFlex limited exible spending account balance to the next plan year. Any amount over $500 will be forfeited.

I understand I have until November 15 to incur dependent care expenses for the plan year. The carryover is not allowed for the

TexFlex dependent care account.

I must le all eligible claims for reimbursement by December 31 of the associated plan year.

I understand that TexFlex account eligibility, enrollment and benets information is available from my employer and at

www.ers.texas.gov. I certify that I have read and agree to all of the conditions and participation rules for this program.

Sign:__________________________________________________ Date:___________________________________________

Page 2 of 3

SECTION E: TEXFLEX LIMITED FLEXIBLE SPENDING ACCOUNT (Fill out only one of the three options in this section, if applicable.)

Enrollment in the TexFlex limited exible spending account (LFSA) is only applicable if you are enrolled in Consumer Directed

HealthSelect

o TexFlex LFSA – for eligible dental and vision out-of-pocket costs excluding healthcare costs. Program has a minimum annual pledge

of $180 and a maximum annual pledge of $2,650 per tax year. You must enroll or make any changes within 31 days of your employment

or qualifying life event. You will receive a TexFlex debit card, at no cost, to pay for dental and vision expenses. There is no annual

administrative fee for the TexFlex LFSA. Note: If you do not check this box, you will not be enrolled in this account.

OPTION 1: NEW ENROLLMENT (Complete only if New Hire/Rehire or Family Status Change.)

I want my monthly deduction to be (not to exceed $220 per month): $ .00

Number of months left in the plan year (September 1 – August 31): x

Annual pledge: $ .00

OPTION 2: INCREASE PLEDGE AMOUNT (Complete only if increasing pledge amount due to a Family Status Change.)

Current annual pledge amount: $ .00

Increase my annual pledge amount to: $ .00

OPTION 3: REDUCTION (Complete only if reducing pledge amount due to a Family Status Change.)

Current annual pledge amount: $ .00

Reduce my annual pledge amount to: $ .00

Family Status Change (FSC) Reference Chart

A qualifying life event (QLE) is an eligible event that allows you to change your enrollment elections within 31 days of that event.

The following are QLEs that correspond with a particular change in your employment or family status. Remember, rules will

determine if you can enroll in or make your requested changes.

Event Qualifying Life Event (QLE) Example Reason

Employee Marital Status Change

Participant gets married MAR

Participant gets a divorce or an annulment DIV

Death of a spouse DOD

Dependent Status Change

Birth of a newborn child BIR

Participant adopts, fosters, or gets court-appointed guardianship of child ADP

Participant gains or loses dependents through death DOD

Dependent becomes eligible or loses eligibility for insurance coverage

(Example: Participant’s spouse is covering their child. The child lost eligibility for the

spouse’s insurance because the child does not attend school.)

DEP

Dependent is related by blood or marriage, and was previously claimed on the

participant’s income tax return, but is no longer eligible to be claimed on participants

income tax return

XMO

Child gets married DGM

Employment Status Change

Participant/Dependent employment status change ESC

Dependent becomes eligible for insurance after a waiting period DWP

Address Change that Changes

Dependent Eligibility

Dependent moves out of health or dental plan service area DMV

Medicare/Medicaid/CHIP Eligibility

Change

Participant/Dependent gains Medicare/Medicaid/CHIP eligibility MDG

Participant/Dependent loses Medicare/Medicaid/CHIP eligibility MDL

Signicant Change in Cost/

Coverage Imposed by Third Party

Signicant change in cost by dependent care provider SCC

Signicant change in cost/coverage of dependent’s health or dental plan (excluding GBP) SCC

HIPP approval or loss of eligibility SCC

Ofce of the Attorney General

(OAG) - Ordered Coverage Change

(Eligibility rules apply for these

dependents)

Participant gains requirement to provide coverage for child through a National Medical

Support Notice (NMSN) issued by the Ofce of the Attorney General (OAG)

(Example: employee receives an NMSN to provide health coverage for his child.)

MSO

Expiration of an NMSM, which is issued by the OAG and requires a participant to provide

coverage for a child.

(Example: employee’s NMSN to provide health coverage for his child expires and the

employee is no longer required to continue coverage for the child.)

MSD*

*Employees must contact their benets coordinator (HHS Enterprise employees contact HHS Employee Service Center) to drop dependents

added with a NMSN.

Benet changes must be consistent with the QLE. Dependent eligibility and enrollment rules apply.

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