Treasurer’s Office/Payroll Forms:
Requisition Form (Click the download arrow and open with Adobe Reader)
Look for the download symbol in the top right corner. Click the arrow.
It should go to your desktop or downloads folder. Find that file and open with Adobe Acrobat Reader. Complete the requisition and save. Attach this file to the email.
Mileage Sheet 2020 added 01/07/20
New Hire and Change of Information Forms:
Form W-4 (form used to withhold Federal Income Tax) updated January 27, 2020
Ohio IT 4 (form used to withhold State Income Tax) updated January 27, 2020
** Change of Address** School District and Municipality Income Tax Form Please complete this form if your home address changes. Newly hired employees will also complete this form so the correct school district and city taxes are withheld.
Direct Deposit (Authorization for direct deposit of payroll) updated 8/9/16
Federal I-9 Form (Federal employment verification form)
SERS New Hire/Rehire Retirement Form (for School Employees Retirement System) Required of ALL classified staff and classified substitute employees.
STRS Enrollment (State Teacher Retirement System application) Required of ALL certified, newly hired teachers and substitute teachers. updated 8/9/16
SERS Re-employed Retiree (State Teachers Retirement System application) Required of ALL certified, newly hired teachers and substitute teachers.
SSA-1945 (Statement concerning jobs not covered under Social Security) Required of ALL employees.
Ohio Ethics Information:
Teacher Discount Programs:
Benefits Connect Trifold (how to use the system) added 8/9/16
Benefits Connect instructions added 8/9/16
Employee HSA Election Form added 11/6/18
Express Care Online added 1/9/18
Insurance Rates 2018-2019 added 6/25/18
Jefferson Health Plan Portal added 2/14/17
RxBenefits HSA added January 27, 2020
RxBenefits PPO added January 27, 2020
Dental Plan Document added March 12, 2013
Eye Med Vision Plan Information updated 8/9/16
EyeMed Select Plan, Group ID #9716747, Employee Id # is your SSN
Flexible Spending Account:
Dependent Eligibility for Medical Insurance:
There are new federal and state mandates requiring insurers to offer dependent coverage to children age 26 (federal) and age 28 (state). This only pertains to medical insurance; it does not apply to dental, vision or life insurance. The eligibility requirements are different for the federal and state mandate, and these differences can be very confusing. Both laws only allow a child to qualify if he/she is not eligible for another employer-sponsored insurance plan.
The state law (under H.B. 1) goes into effect first – on July 1, 2010. Under the Ohio law, children can be covered until age 28. The child must be unmarried, but does not have to live with the parents. The child will have a separate policy and be charged for the plan. The child must be an Ohio resident or a full-time student at a public or private institution of learning and must not be eligible for coverage under Medicaid or Medicare.
The federal law (under Patient Protection and Affordable Care Act of 2010) goes into effect on July 1, 2011. Under the federal law, children can be covered until age 26. The child can be married or unmarried, and does not have to live with the parents. The child will be covered under the parent’s family plan and cannot be charged for a separate plan. The child does not have to be an Ohio resident or a student and may be eligible for coverage under Medicaid or Medicare.
Currently, monthly rates are available. The rate will be computed annually by the health care consortium. Contact the Treasurer’s office if you have any questions.
Medicare Prescription Drug Costs Information:
Family Medical Leave Act Information:
The Family Medical Leave Act entitles employees to take up to 12 weeks of leave (paid, unpaid, or a combination of both), a job-protected leave in a 12-month period. The District will continue to pay its contribution necessary to continue all medical insurance plans while the employee is on Family Medical Leave.
If you receive FMLA paperwork from the Treasurer’s Office it means that we are required to send it according to law and our board policy. FMLA runs concurrent with sick leave, as long as the employee has a sick leave balance. FMLA will begin at the beginning of the leave. Please sign the form and have your physician complete the remainder of the paperwork and return it to the Treasurer’s Office. Please contact the Treasurer’s Office if you have any questions.
If you would like further information regarding the Family Medical Leave Act, please see the U.S. Department of Labor’s website at http://www.dol.ogv/whd/fmla/index.htm
Notice of Privacy Practices