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UA Statewide Employee Forms (A-Z Forms Index)
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HR Forms Index

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Form Name Available Formats
(Icon Legend)
Form Descriptions
8233 Form Adobe PDF format file Computer enterable Adobe PDF format file To request a tax treaty exemption for a non-resident alien.
8233 Form Attachments Adobe PDF format file Required attachments for the 8233 form by type and country.
8233 Form Instructions Adobe PDF format file Instructions for requesting a tax treaty exemption for a non resident alien.
A
Alaska Administrative Code Adobe PDF format file Chapter 52 Executive Branch Code of Ethics definitions.

Alaska Executive Branch Ethics Act Quick Reference

Adobe PDF format file Quick reference regarding workplace ethics.
Automatic (Direct) Deposit Request Form Adobe PDF format file Computer enterable Adobe PDF format file To add, change, or delete the automatic (direct) deposit of pay to bank accounts.
B
Beneficiary Designation Form Adobe PDF format file Computer enterable Adobe PDF format file To declare beneficiaries for basic life, accidental death & dismemberment, or supplemental life insurances.
Blue Cross Health Care Claim Form Adobe PDF format file To submit health care claims to Blue Cross/Blue Shield.
C
Campus Card Deduction Form Adobe PDF format file To request a payroll deduction to credit a campus card (UAA Wolfcard, UAF Polar Express card, and/or UAS Whale Card).
Caremark Prescription Claim Form Adobe PDF format file For Caremark pharmacy claims.
Change Form Adobe PDF format file Computer enterable Adobe PDF format file To request a change to name, address, phone number, marital status, and/or Social Security number for an employee, student, and/or vendor.
COBRA Rights and Responsibilities Summary Adobe PDF format file Summary of COBRA Rights and Responsibilities.
D
Day Counter Adobe PDF format file To assist with performing a substantial presence test for non-resident aliens.
Day Counter -
Leap Year
Adobe PDF format file To assist with performing a substantial presence test for non-resident
aliens during leap years.
Demographic - Personal Data Adobe PDF format file Computer enterable Adobe PDF format file To document employee demographic information.
Direct Deposit Request Form Adobe PDF format file Computer enterable Adobe PDF format file To add, change, or delete the direct deposit of pay to bank accounts.
Dummy Job Checklist for Payroll Adjustment Adobe PDF format file Checklist for Payroll to request Personnel set up a job record in order to process a payroll adjustment. (HR office use only).
E
Employee Selected Deduction Form Adobe PDF format file Used for optional payroll deductions not related to benefits.
Employee Work Activity Outside of Alaska Form Adobe PDF format file Used to report employee work activity outside of Alaska.
Employment in a Job Not Covered by Social Security Adobe PDF format file Statement to be given to employees in a job not covered by Social Security.
Employment of Immediate Family Members Disclosure Form Adobe PDF format file For UA employees to disclose the employment of immediate family members.
Employment or Service Outside UA Disclosure Form - Faculty

Computer enterable Adobe PDF format file

Used for the disclosure of other employment or service outside of UA for Faculty.
Employment or Service Outside UA Disclosure Form - Staff/Student

Computer enterable Adobe PDF format file

Used for the disclosure of other employment or service outside of UA for Staff and Students.

Employment or Service Outside UA Memo

Adobe PDF format file Memo regarding ethics disclosure guidelines for UA faculty and staff.
Estate Disbursal Adobe PDF format file To request dispursal of pay to employee estate (HR office use only).

Ethics Act Compliance Regarding "Works" - United Academics Faculty

Adobe PDF format file Summary of UNAC faculty "Works" compliance guidance.

Ethics Determination Request Form

Adobe PDF format file Confidential Request for Ethics Determination

Ethics Disclosure - Notification of Receipt of Gift

Adobe PDF format file To disclose the receipt of a gift by the employee or a member of the employee's family.
Ethics Worksheet Answer Guide Adobe PDF format file Answers for the Executive Branch Ethics Act - Worksheet
Executive Branch Ethics Act - Worksheet Adobe PDF format file To determine an employee's understanding of the Chapter 52 Executive Branch Code of Ethics
F
Fidelity Beneficiary Designation Form Adobe PDF File Format To declare or change beneficiaries for the Fidelity Voluntary TDA, ORP, and/or Pension plans.
Fidelity Address/Name Change Form Adobe PDF File Format To change your address and/or name or provide your birthdate to Fidelity.
Fidelity Online Enrollment Guide Adobe PDF format file Fidelity enrollment instructions on opening a retirement account online.
Fidelity Transfer/Rollover Form Adobe PDF format file To move assets from another investment provider to a Fidlity retirement account or to consolidate multiple employer sponsored retirements accounts at Fidelity.
Fidelity Voluntary TDA, ORP, & Pension Plan Enrollment Form Adobe PDF format file To select investment options and beneficiary designation for the Fidelity Voluntary TDA, ORP, and/or Pension plans.

Financially Interdependent Partners (FIP) Explanation

Adobe PDF format file To explain and determine FIP eligibility.

Financially InterdependentPartners (FIP) Statement

Adobe PDF format file To declare FIP eligibility.
FML: Q & A's
Adobe PDF format file Questions and answers regarding Family Medical Leave (FML).
FML Request Form Adobe PDF format file To request FML leave for a serious health condition (to be completed by employee).
FML: Certification of Health Care Provider for Employee's Serious Health Condition External Site To support an employee's FMLA leave request due to the employee's own serious health condition (to be completed by the employee, employer, and the employee's health care provider).
FML: Certification of Health Care Provider for Family Member's Serious Health Condition External Site To support an employee's FMLA leave request due to a family member's serious health condition (to be completed by the employee, employer, and the family member's health care provider).
FML: Certification of Qualifying Exigency for Military Family Leave External Site To support an employee's FMLA leave request due to a qualifying military exigency (to be completed by the employee and employer).
FML: Certification for Serious Injury or Illness of Covered Servicemembers - for Military Family Leave External Site To support an employee's FMLA leave request due to the serious health condition of a covered servicemember (to be completed by the employee or covered servicemember, employer, and DOD health care provider).
fsaATLAS Access Request Form Adobe PDF format file To request access to fsaATLAS.

FSA Claim For Medical And Dependent Care Form

Adobe PDF format file To submit a claim for your flexible spending account.
FSA Direct Deposit For Medical And Dependent Care Form Adobe PDF format file To establish direct deposits of flexible spending account payments.
I
I-9 Form Computer enterable Adobe PDF format file To verify employment eligibility.
Independent Contractor Adobe PDF format file Form for non-resident aliens to claim independent contractor (lecturer) status.
Injury/Illness Form (Previous) Adobe PDF format file To document an injury or illness prior to employment at UA.
International Form Adobe PDF format file Computer enterable Adobe PDF format file To determine federal tax responsibility for non-resident aliens.

International Form Attachment

Microsoft Excel format file An Excel spreadsheet template to record additional travel dates that will not fit on the international form. This form should always be attached to an international form and never stand alone.
International Scholarship Form Adobe PDF format file To determine federal tax responsibility for non-resident aliens on scholarships.
J
Job Form Adobe PDF format file Computer enterable Adobe PDF format file To record additions, deletions, or changes to job assignments.
L
Labor Redistribution Adobe PDF format file Computer enterable Adobe PDF format file To document redistribution of labor charges.
Leave Share Donation Form Adobe PDF format file To give leave donations to leave share program participants (to be completed by employee donating leave).
Leave Share Transfer Request Form Adobe PDF format file To receive leave donations from the leave share program (to be completed by employee receiving donated leave).
Leave/Earnings Adjustment Adobe PDF format file Computer enterable Adobe PDF format file To document adjustments to leave and earnings.

Leave Without Pay Request Form (FML, Sick Leave, Leave of Absence)

Adobe PDF format file To arrange benefit payments while on FML leave w/o pay (FMLWOP), sick leave w/o pay (SLWOP), or leave of absence w/o pay (LOAWOP).
Local 6070 Membership Dues or Fees Deduction Form Adobe PDF format file To initiate payroll deductions for Local 6070 union fees or dues.
N

NRA FAQ's

Adobe PDF format file FAQs for Payments Made to Foreign Individuals and Foreign Entities.

NRA - Foreign Entity Form

Adobe PDF format file Foreign Entity Form.

NRA - IRS Regulations for Foreign Nationals

Adobe PDF format file Powerpoint Paying Foreign Nationals and Foreign Entities: IRS Compliance.

NRA - Procedures

Adobe PDF format file Payment/Contract of Foreign Entity Procedures.

NRA Scholarship Withholding Worksheet 2009

Adobe PDF format file To determine the amount of personal allowances, if any, you may claim as deductions when calculating applicable
US federal income tax withholding from your non-resident scholarship or fellowship for 2009.

NRA Workteam Contact Listing

Adobe PDF format file Contact listing for the NRA Workteam.
O
ORP Enrollment or Fund Sponsor Change Form Adobe PDF format file To enroll in the Optional Retirement Program (ORP) or change your fund sponsor (Fidelity, TIAA-CREF, Lincoln, or Valic).
P
Paycheck Reissue Adobe PDF format file Computer enterable Adobe PDF format file To document a reissue of a pay.
Payroll Adjustment Adobe PDF format file Computer enterable Adobe PDF format file To document adjustments to a pay.
Pension/ORP Fund Sponsor Enrollment or Change Form Adobe PDF format file To select fund sponsor(s) for UA Pension and/or employee and employer contributions for ORP.
PERS/TRS Forms External Site The State of Alaska Division of Retirement forms page.
PERS/TRS/ORP Option
Adobe PDF format file To certify the notification of participation in the PERS, TRS, or ORP retirement plan.
PharmaCare Physician Prior Authorization Request Form (for prescriptions) Adobe PDF format file To be completed by patient's physician - to request authorization for prescription exceptions (i.e., medication usage past certain time period, specific medication brand, etc.).

PharmaCare Prescription Drug Forms
(Effective 7/1/06)

PharmaCare Site Site contains reimbursement form for prescription drug claims; site also has other prescription related forms.
Position Description Glossary Adobe PDF format file A listing of commonly used terms for the position description.
Position Requisition Adobe PDF format file Computer enterable Adobe PDF format file Used to document a position request.
R
Relocation Allowance Adobe PDF format file To request a relocation allowance.
Retirement Plan Decision Tree
(Regular Faculty or Academic Executives)

Adobe PDF format file

Decision tree that assists with Retirement Plan Notification Form for regular faculty or academic executives.
Retirement Plan Decision Tree
(Regular Staff or Non-Academic Executives)
Adobe PDF format file Decision tree that assists with Retirement Plan Notification Form for regular staff or non-academic executives.
Retirement Plan Election Form
(TRS/PERS/ORP)
Adobe PDF format file To elect participation in TRS, PERS, or ORP based on the employee's retirement plan eligibility.

Retirement Plan Notification Form
(Regular Faculty or Academic Executives)

Adobe PDF format file To notify eligible regular faculty or academic executive employees of their retirement options and elections.

Retirement Plan Notification Form
(Regular Staff or Non-Academic Executives)

Adobe PDF format file To notify eligible regular staff or non-academic executive employees of their retirement options and elections.
S
Salary Advance Request Form Adobe PDF format file To request a salary advance for extreme family emergencies.
Social Security Card Application (SS-5 Form) External Site Instructions and form to apply for a Social Security card.
Social Security Consent for Release of Information (SSA-3288 Form) Adobe PDF format file

SSA consent form and instructions for SSN applicant to authorize the release of their SSN to the University of Alaska.

Student Enrollment Verification/Dependent Health Care Eligibility Adobe PDF format file Computer enterable Adobe PDF format file To verify student enrollment and/or to notify employees of dependent (child) health care coverage eligibility.
Student Employee Waiver Form Adobe PDF format file For student employees to request a waiver of UA Student Employment policies (e.g. minimum GPA, weekly work hours limit).
Student Status Verification Form Adobe PDF format file Computer enterable Adobe PDF format file Required for student employment only.
System Termination Adobe PDF format file Computer enterable Adobe PDF format file To document termination of employment.
System Termination - Employee Information Adobe PDF format file Computer enterable Adobe PDF format file Termination information for UA employees in letter format.
T
TDA Salary Reduction Agreement Form Adobe PDF format file Computer enterable Adobe PDF format file To establish or change contributions to a tax deferred annuity.
TIAA-CREF Online Enrollment Guide Adobe PDF format file TIAA-CREF enrollment instructions on opening a retirement account online.
TIAA-CREF
ORP Enrollment Form
Adobe PDF format file To select investment options for TIAA-CREF Optional Retirement Program (ORP).
TIAA-CREF Pension Plan Enrollment Form Adobe PDF format file To select investment options for TIAA-CREF Pension Plan.
TIAA-CREF
TDA Enrollment Form
Adobe PDF format file To select investment options for TIAA-CREF tax-deferred annuity (TDA).
TIAA-CREF Transfer/Rollover Authorization Form Adobe PDF format file To authorize the transfer/rollover of funds to TIAA-CREF annuities or Rollover IRA contracts.
Taxable Status Determination Form Adobe PDF format file Computer enterable Adobe PDF format file UA form to determine taxable status of immigrants to U.S.
Tax Treaty Summary - Compensation-Related Adobe PDF format file Summary of tax treaty requirements related to nonresident alien employee compensation.
Tax Treaty Summary - Scholarship and Fellowship-Related Adobe PDF format file Summary of tax treaty requirements related to nonresident alien scholarships and fellowships.
Tax Treaty Withholding Summary - Accounts Payable Adobe PDF format file Summary of tax withholding for nonresident aliens per tax treaty.
Timesheet Exempt Adobe PDF format file Computer enterable Adobe PDF format file To report time worked for exempt personnel classifications.
Timesheet Nonexempt Adobe PDF format file Computer enterable Adobe PDF format file To report time worked for non-exempt personnel classifications.
TRS/ORP Option
(Faculty or Academic Executives)
Adobe PDF format file To certify the notification of participation in the TRS or the ORP retirement plan.
TRS/PERS Forms External Site The State of Alaska Division of Retirement forms page.
(Tuition) Waiver Request - UA Education Benefit Adobe PDF format file For use by eligible employees for the UA employee education benefit.
UA Approved Non-credit Courses for Fall 2009

Adobe PDF format file

UA approved non-credit courses for Fall 2009 that qualify for the UA employee education benefit.
UA Approved Certified Public Manager (CPM) Courses

Adobe PDF format file

UA approved CPM courses that qualify for the UA employee education benefit.
U
UA Choice Enrollment Guide
(For coverage effective as of July 1, 2009.)
Adobe PDF format file UA Choice Enrollment Guide for plan period of July 1, 2009, through June 30, 2010.
UA Choice Health Plan Enrollment Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file To enroll employee and dependents in the UA health care plan for the plan period of July 1, 2009, through June 30, 2010.
UA Choice Opt Out Form - FY10
(For plan period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file To elect to opt out of UA health care coverage during the plan period of July 1, 2009, through June 30, 2010.
UA Choice Supplemental Benefit Election Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file To add or delete employee selected benefits and/or deductions (e.g. FSA, AD&D, Supplemental Life) during the plan period of July 1, 2009, through June 30, 2010.
UA Supplemental Life Evidence of Insurability (EOI) Form - FY10
(For coverage period of July 1, 2009, through June 30, 2010.)
Adobe PDF format file Employees electing more than $200,000 in supplemental life coverage are required to complete the evidence of insurability form and submit it to their HR office along with with the UA Choice Supplemental Benefit Election Form.
UA Computer Account Request Form Adobe PDF format file ITS form to request access to email, Meeting Maker, domains, etc.
UAFT Disability Leave Bank - Application for Withdrawal Adobe PDF format file For UAFT employees to request withdrawal of disability leave from the UAFT Disability Leave Bank.
UAFT Disability Leave Bank - Usage Procedures Adobe PDF format file Usage procedures for a UAFT employee to request leave from the UAFT Disability Leave Bank.
UAFT Service Fee Deduction Form Adobe PDF format file To initiate a payroll deduction for UAFT union service fees.
UAFT Service Fee Revocation Form Adobe PDF format file To stop a payroll deduction for UAFT union service fees.
UA System Administrative Access Request Form Adobe PDF format file ITS form to request access to UNIX, Oracle, and SCT Banner
United Academics Adjuncts AAUP/AFT Dues or Agency Fee Deduction Form Adobe PDF format file To initiate payroll deductions for United Academics Adjuncts union dues or agency fees.
United Academics Dues or Agency Fee Deduction Form Adobe PDF format file To initiate payroll deductions for United Academics union dues or agency fees.
United Academics Dues or Agency Fee Revocation Form Adobe PDF format file To stop payroll deductions for United Academics union dues or agency fees.
V
Visa Classifications Adobe PDF format file Listing of visa classifications, eligibility, and benefits.
Visa Waiver Program Adobe PDF format file Document with details of the visa waiver program (VWP) and the qualifying countries.
Void Adjustment Adobe PDF format file Computer enterable Adobe PDF format file To document a void of a payroll payment.
VSP Out-of-Network Reimbursement Form Adobe PDF format file Effective 7/1/04: To submit a claim to VSP (vision vendor) for out-of-network provider reimbursements.
W
W-4 Form (2009)
Computer enterable Adobe PDF format file To declare your federal tax withholding status for 2009.
W-4 Form (NRA) Computer enterable Adobe PDF format file Form to declare your federal tax withholding status. Pre-completed for nonresident aliens.
W-5 Form (2009)
Computer enterable Adobe PDF format file To request, if eligible, receipt of part of the earned income credit (EIC) in advance with your pay.
W-8BEN Form Adobe PDF format file Form to claim certification of foreign status of beneficial owner for U.S. tax withholding.
W-8BEN Instructions Adobe PDF format file W-8BEN form instructions (used to claim certification of foreign status of beneficial owner for U.S. tax withholding).
W-9 Form Adobe PDF format file To Request Taxpayer Identification Number
Waiver Request - UA Education Benefit Adobe PDF format file For use by eligible employees for the UA employee education benefit.
UA Approved Non-credit Courses for Fall 2009

Adobe PDF format file

UA approved non-credit courses for Fall 2009 that qualify for the UA employee education benefit.
UA Approved Certified Public Manager (CPM) Courses

Adobe PDF format file

UA approved CPM courses that qualify for the UA employee education benefit.

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