Payroll and Benefit Information at Separation

EMERGENCY PAY ADVANCE REQUEST Pay advances are for EMERGENCIES ONLY. Requests must comply with Oregon Accounting Manual Policy 45.25.00.PO and administrative rules or collective bargaining agreements.

About the Employee: (Completed by Employee) INSTRUCTIONSEmployee ID for Number: Customizing (Please do not usethis your Form: Social Security number here.)

Save this form asOR a new __ __ document ______before__ __ changing (Don’t know anything. this? This Find preserves it on your thepaystub, template or askfor futurepayroll to help.) OREGON STATEWIDEuse. Name: Last, First, MI Daytime Telephone No. PAYROLL SERVICES (OSPS) Everything in REDRepresentation must remain Statusunchanged. This includes font size, document location, table (503) 378-3518 fax formatting and words. The one exception is to change everything to black print before finalizing. E-mail:  Represented by ______ Unrepresented: Exec Service [email protected] Elements that must Unrepresented: stay the same areMgmt in redService on the document. They Unrepresented: include: Other ______Online Resource Center: http://go.usa.gov/bEJk Form titleAbout in header the Request: (Completed by Employee) Contact your agency payroll unit for documentation requirements. INSTRUCTIONS TO First part Chooseof form subtitle,a reason up from through the list the below. word “and”Enter thefollowing code in the the OAM “Reason policy Code” citation box below. EMPLOYEES: Complete this form online“Instructions at: DEC to – Payroll”Death in family in the necessitating left margin unforeseen HOM – Destruction or major damage to home http://go.usa.gov/BVNG expenditures or travel requiring immediate substantial cash  “OSPS UseCAR Only” – Major date-stamp car repair table such inas leftengine, margin NEW – New employee lack of funds transmission, or catastrophic failure MOV – Unreimbursed moving expenses due to 1. Print form and attach  Form identificationTHF – Theft “Revised” of cash representing and the Form major number portion of(you transfermay change or promotion. the revision This doesdate) not include documentation. most recent pay personal moving situations such as purchasing a ACC – Automobile accident leading to loss of home or renting a different residence. 2. Obtain supervisor or Entire section titled “Agency Payroll Authorization Request to OSPS” manager signature. vehicle use OTH – Other (explain) ______SCK – Accident or sickness (self or family) ______3. Return form to your agency All of the black textrequiring is available immediate to substantialyou for customizing. cash This includes______adding/removing reasons for payroll officethe. request, or changing instructions, or modifying the form in any way. This is a good place to put in agency-specific (or contract-specific) reasons that pay advances are allowed. It’s also a good place to Reason Code (see above) Request Amount1 Eligible Hours (Work/Leave Taken INSTRUCTIONSoutline TO exactly what type of documentation you require, and for which reasons. Including Holiday), Not Paid PAYROLL OFFICES:  $ ______.00 1. Complete AgencyIf your Payroll form is longer than one pag, make sure the Max “Agency (60% Payrollof gross) Authorization…” section remains Authorization on the first page. IfThis approved, is default I willtemplate collect behavior this emergency which you pay can advanceonly change check intentionally. by: 2. Sign and date where indicated.  Pick up at Payroll Office  Shuttle / Mail to Worksite  Mail to Home Address on File To change the information in the left margin or in the header, you need to do so using the 1I authorize my agency payroll office to deduct the amount I indicate above, or a lesser amount as 3. Fax form to header/footerOSPS. view. In Word 2003, go to View > Header and Footer to make that information active so calculated by the payroll office for available funds, from my next paycheck. you can change it. In Word 2007, use the “Header & Footer” controls on the “Insert” ribbon. For Agency Use Employee Signature Date Rejected: To change the Oregon state seal to another logo of your choice, activate he header/footer view as  Does not comply with Supervisor/Manager Approval Signature Date regulations outlined above. Click the seal and delete. Insert the logo of your choice; resize it as needed to fit in the  Too many requestsspace allotted.this period  Other (specify): Payroll Office Available Pay Calculation: To change the red fonts to black, activate the header/footer view as outlined above. Highlight the red Hrs Worked ÷ Avail Hrs x Mo. Salary = Gross x 60% - Wage = Available OSPS Useareas Only and change the font color to black. Attachment Received Date Stamp Hrs Worked (Hourly EE) x Hourly Rate To change the divider line from red to black, activate the header/footer view as outlined above. Right- click on the line and choose “Format Auto Shape”. Change the color to black.

Agency Payroll Authorization Request to OSPS: Once you’rePlease produce solid an off-cycle, with manual these check for instructions, the following individual and selectamount: Employee ID Agency No. Pay Period End Check Date Check Amt this text ORbox ______(click ______an __ edge so you see its outline) and delete Revised 02/2016 Form No. 75.45.02.FO OSPS Authorized Signature for Pay Advances Date Prepared by (if different)