C:\Users\janet.korsmo\Desktop\New EE Webpages\Personal Data Form rvsd 3_2014 form filldoc.doc
PERSONAL DATA FORM
New Hire - Complete Entire Form Existing Employee – Complete changes only
Employee Name (as it appears on your SS card):
Preferred Name (if applicable)
Employee/Student ID Number or SSN
Mailing Address:
(
If different from home address
)
City, State and Zip Code:
Cell / Other Phone &/or email address:
Marital Status: Registered Gender: Male
Domestic Female
Married Single Partnership
Y N
Highest Degree/Certificate: _________ Grad. Month &Yr: ___ /____
Major/Certificate: _________________________________________________
Institution/Trade School:__________________________________________
II. EMERGENCY CONTACT INFORMATION
Primary Emergency Contact:
City, State and Zip Code:
III. DESIGNATION OF PERSON AUTHORIZED TO RECEIVE STATE WARRANTS
(Gov. Code § 12479)
Student Assistants complete designation on CSU SPAR
Pursuant to Section 12479 of the Government Code, I hereby designate the following person who, notwithstanding any other provision of law, shall be entitled upon my death to receive all state warrants excluding warrants for payment of death benefits and refund of
employee retirement contributions that would have been payable to me had I survived.
DESIGNEE INFORMATION (
Must be 18 years of age or older)
Name (First, Middle, Last):
City, State and Zip Code:
I hereby revoke any previous designations filed by me. If the above named designee does not file a written request with the Human Resources Office of my employer state agency for such warrants within sixty (60) days after the date of my death, this designation shall become
null and void. This designation will remain in full force and effect during my employment with any California state agency until revoked in writing by me. This designation will terminate on the date of my permanent separation from said employment. I hereby subscribe to this
statement by signing below.
PRIVACY NOTICE: The Information Practices Act of 1977 (civil Code Section 1798.17) and the Federal Privacy Act (5USC 52a, subd. (e)(3) require that this notice be provided when collecting personal information from individuals. Information requested on this form is
used by the employing personnel/payroll office for the sole purpose of identifying the designee authorized to receive warrants payable to the employee had he/she survived. Legal references authorizing maintenance of this information are mandated by Government Code
Section 12479 and the State Administrative Manual Sections 8477.1-8477.27. Providing personal information is mandatory. Non-compliance in providing your social security number and name will delay the identification and release of state Warrants. Information furnished
on this form may be transferred to the following governmental agencies: State Controller’s Office, Federal Internal Revenue Service, California State Franchise Tax Board, other state income tax bureaus and other governmental entities when required by state or federal law.
This form and all personal information contained therein are maintained by the employing personnel/payroll office. Employees have the right of access to copies of their Designation of Person Authorized to Receive Warrants form upon request.
__________________________________________________ ___________________________________________________
Authorized Official’s Signature Title
Trustees of the California State University and Colleges
California State University, Channel Islands
