Statewide Office of Human Resources

A-Z Index of Forms

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

 

A

Alaska 529 Payroll Deduction Request Form

PDF

For employees to start, change, add, or discontinue a deduction from their university pay for Alaska 529 account(s).

Alaska Administrative Code

PDF

Chapter 52 Executive Branch Code of Ethics definitions.

Alaska Executive Branch Ethics Act Quick Reference

PDF

Quick reference regarding workplace ethics.

Annual Leave Cash-In Request for Non-Union Employees

Electronic Form

For eligible, non-union employees to request a cash-in of their annual leave hours. Refer to the guidelines for more information.

 
B 

Beneficiary Designation Form

PDF, Enterable PDF

To declare beneficiaries for basic life, accidental death & dismemberment, or supplemental life insurances.
(Premera) Blue Cross Blue Shield Health Care Claim Form

Word
To submit health care claims to Premera Blue Cross Blue Shield.
 
C 

Campus Card Deduction Form

PDF

To request a payroll deduction to credit a campus card (UAA Wolfcard and/or UAS Whale Card).

Change Form

PDF

To request a change to name, address, phone number, marital status, and/or Social Security number for an employee, student, and/or vendor.

Employees and students can change their address online using UA Online. 

COBRA Rights and Responsibilities Summary

PDF

Summary of COBRA Rights and Responsibilities.
 
D 

Day Counter

PDF

To assist with performing a substantial presence test for non-resident aliens.

Day Counter - Leap Year

PDF

To assist with performing a substantial presence test for non-resident aliens during leap years.

Demographic - Personal Data

PDF

To document employee demographic information.

(Payroll) Direct Deposit Request Form

Electronic Form

To start, change, or stop the deposit of your biweekly pay. For instructions, refer to Direct Deposit of Your Pay or page 3 of the form.

***For non-payroll setup (travel reimbursements, financial aid, student refunds, etc.), login to uaonline.alaska.edu and select Finance/Direct Deposit Services.

Dummy Job Form & Checklist for Payroll Adjustment

PDF

Checklist for Payroll to request from Personnel the setup of a temporary job record and deductions for an employee payroll adjustment. (HR office use only).
 
E 

Employee Selected Deduction Form

Online Form
(UA login required)

To request setup of optional payroll deductions not related to benefits.

Employee Work Activity Outside of Alaska Form

Procedures
(review before completing form)

Online Form
(UA login required)

For the department to initiate the approval process for a University employee who is working or will be working outside the state of Alaska for either a) 30 consecutive days, OR
b) any length of time, and is a legal resident of a state or country outside of the state of Alaska.

Before completing the online form, review the "Work Activity Outside of Alaska" procedures linked at left.

Employee Cancellation of Work Activity Outside of Alaska Form

Procedures
(review before completing form)

Enterable PDF

For the employee and department to report the cancellation of an employee's work activity outside of Alaska.

Before completing the form, refer to the cancellation section of the "Work Activity Outside of Alaska" procedures linked at left.

(Statement Concerning Your) Employment in a Job Not Covered by Social Security (Form SSA-1945)

Enterable Form (SSA Site)

Form SSA-1945 to be provided to / completed by employees hired January 1, 2005, or later, in a job that is not covered by Social Security. The statement covers the potential effect of two provisions on Social Security benefits.

(Disclosure of) Employment of Immediate Family Member Form

PDF

For UA employee disclosure of the employment of immediate family members.

Employment or Service Outside UA - Memo

General Counsel Ethics Forms and Training
Memo regarding ethics disclosure guidelines for UA faculty, staff, and student employees.

Employment or Service Outside UA Disclosure Form - Faculty, Staff, & Student Employees

Online Form

For employee disclosure of other employment, service, or activities outside of UA.

Estate Disbursal Form & Instructions

PDF

To request disbursal of pay to employee estate (HR office use only).

Estate Form - Affidavit for Collection of Personal Property of Decedent (Form P-110)

Enterable PDF
(AK Court System site)

State of Alaska Court System form for use by a successor to claim/collect property from a decedent's estate in the event that no will is present.

Ethics Act Compliance Regarding "Works" - United Academics Faculty

PDF

Summary of UNAC faculty "Works" compliance guidance.

(Ethics) Alaska Administrative Code

PDF

Chapter 52 Executive Branch Code of Ethics definitions.

(Ethics Act Quick Reference) Alaska Executive Branch

PDF

Quick reference regarding workplace ethics.

Ethics Determination Request Form

PDF

Confidential Request for Ethics Determination

Ethics Disclosure - Interest in Grants, Contracts, Leases, or Loans

PDF

For employee disclosure of a personal or financial interest in a state grant, contract, lease, or loan held by the employee or a family member and awarded, executed, or administered by the university.

Ethics Disclosure - Notification of Receipt of Gift

PDF

For employee disclosure of the receipt of a gift by the employee or a member of the employee's family.

Ethics Worksheet Answer Guide

PDF

Answers for the Executive Branch Ethics Act - Worksheet

Executive Branch Ethics Act - Worksheet

PDF

To determine an employee's understanding of the Chapter 52 Executive Branch Code of Ethics.
 
F 

FFA (Fire Fighters Association) Membership
Dues Deduction
Form

UA Labor Relations site

To initiate payroll deductions for Fairbanks Fire Fighters Association Local 1324 union dues.

FFA (Fire Fighters Association) Voluntary
PAC Deduction Form

UA Labor Relations site

To initiate payroll deductions for Fairbanks Fire Fighters Association Local 1324 Voluntary PAC contributions.

FICA Medicare/Social Security Refund -
Employee Letter Template

HR Office Use Only

Word format

For the Payroll office to inform an employee if excess Medicare and/or Social Security taxes were taken from their earnings and the method of refund.

Fidelity Beneficiary
Designation Form

PDF

To declare or change beneficiaries for the Fidelity Voluntary TDA, ORP, and/or Pension plans.

Fidelity Enrollment
and Beneficiary Designation Form

PDF

To enroll in and designate beneficiaries for the Fidelity Voluntary TDA, ORP, and/or Pension plans.

Fidelity Address/Name
Change Form

PDF

To change your address and/or name or provide your birthdate to Fidelity.

Fidelity Online
Enrollment
Guide

PDF

Fidelity enrollment instructions on opening a retirement account online.

Fidelity
Transfer/Rollover
Form

PDF

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

PDF

To select investment options and beneficiary designation for the Fidelity Voluntary TDA, ORP, and/or Pension plans.

Financially
Interdependent
Partner (FIP)
Explanation

PDF

To explain and determine FIP eligibility.

Financially
Interdependent
Partner (FIP)
Imputed Taxable
Income Amounts for
FY18

PDF

The imputed taxable income rates for FIP dependent health care coverage.

For plan period of July 1, 2017, through June 30, 2018.

Financially
Interdependent
Partner (FIP)
Statement


PDF
To declare FIP eligibility.

FML: Q & A's

PDF

Questions and answers regarding Family Medical Leave (FML).

FML Request Form

PDF

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).

FML: Certification for
Serious Injury or
Illness of a Veteran for Military Caregiver Leave

External site

To support an employee's military caregiver FMLA leave request due to the serious health condition of a covered veteran (to be completed by the employee or covered servicemember, employer, and DOD health care provider).

Flexible Spending Account (FSA) Information

Benefits site

Information and links for the University of Alaska's FSA program.

FSA - ASIFlex General FSA Claim Form
(Medical and/or Dependent Care)

***For expenses as of 7/1/16

ASIFlex Site

To submit an FSA reimbursement request for medical and/or dependent care expenses incurred for the plan year. Claims can also be filed online through the ASIFlex site.

***For expenses incurred on or after 7/1/16.***
 
I 

I-9 Form

Enterable PDF (External Site)

Non-Enterable PDF (External Site)

To verify employment eligibility within the U.S.

Independent Contractor (Lecturer) Disclosure Statement

PDF

Form for non-resident aliens to claim independent contractor (lecturer) status.

 ISSM Access Request Form

PDF

 

To request user access to ISSM ( formerly fsaATLAS)

(For use by UA personnel in international student/scholar management.)

 
J 

Job Form

PDF, Enterable PDF

Job Form Submissions – New Hire & Re-Hires – Currently Inactive Employees

Job Form Submission - Existing Employee Changes – Currently Active Employees

 

 

 

To record additions, deletions, or changes to job assignments.

NEW! Electronic Submission of Job Forms is now available for UAF and UAA satellite departments. Submit job forms and supporting documentation through NextGen rather than delivering hard copy forms. This feature will be coming to the rest of UA September 16, 2019.

 
L 

Labor Redistribution Form

PDF, Enterable PDF

To request/document redistribution of labor charges.

Leave Share Donation Form

Electronic Form

For UA employees to donate sick leave to leave share program participants (to be completed by employee donating leave).

Leave Share Transfer Request Form

PDF

For UA employees to request leave donations from the leave share program (to be completed by employee receiving donated leave).

Leave/Earnings Adjustment Form

PDF, Enterable PDF

For Payroll offices to document adjustments to leave and earnings (HR use only).

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

PDF

For UA employees to request/arrange benefit contributions 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

UA Labor & Employee Relations site

To initiate payroll deductions for Local 6070 union fees or dues.
 
 
N 

NRA FAQs - Payments to Foreign Individuals & Foreign Entities

PDF

FAQs for payments made to Foreign Individuals and Foreign Entities.

 

NRA Workteam Contact Listing

PDF

Contact listing for the NRA Workteam/Systemwide International Administrative Services contacts.
 
P

Paycheck Reissue Form

PDF, Enterable PDF

For Payroll offices to document a reissue of a pay (HR use only).

Payroll Adjustment Form

PDF, Enterable PDF

For Payroll offices to document adjustments to pay (HR use only).

Pension / ORP Fund Sponsor Enrollment or Change Form

PDF

To select fund sponsor(s) for UA Pension and/or employee and employer contributions for ORP.

Performance Appraisal Form

Enterable PDF***

Template for an employee and their immediate supervisor to appraise the employee's work performance, set future goals and career development, and provide feedback. Definitions are included at the end of the form for reference.

***Note: To save a copy of the PDF file with your entries, use Acrobat Reader 8.0 or higher to complete the form.

PERS / TRS Forms & Brochures

External site

The State of Alaska Division of Retirement & Benefits forms and brochures page for the Public Employees Retirement System (PERS) and Teachers Retirement System (TRS).

PERS / TRS Retro Adjustments
(Excel template)

FY17 | FY16

For Payroll offices to record and calculate retroactive payroll adjustments for employee contribtutions to PERS and TRS (HR use only).
Premera Blue Cross Blue Shield Health Care Claim Form

Word
To submit health care claims to Premera Blue Cross Blue Shield of Alaska.

Premera (Express Scripts/Medco) Mail Prescription Claim Form

PDF

For Premera (Express Scripts/Medco) mail order claims for prescriptions ordered beginning July 1, 2013.

Premera (Express Scripts/Medco) Primary Insurance Prescription Claim Form

PDF

For Premera (Express Scripts/Medco) insurance claims for prescriptions purchased beginning July 1, 2013. This form should be used when the UA Choice program is the primary insurance provider.

Premera (Express Scripts/Medco) Secondary Insurance Prescription Claim Form

PDF

For Premera (Express Scripts/Medco) insurance claims for prescriptions purchased beginning July 1, 2013. This form should be used when the UA Choice program is the secondary insurance provider.

Premera Blue Cross Blue Shield Medical Travel Support Claim Form

PDF

To claim benefits through Premera Blue Cross Blue Shield's Medical Travel Support program, which offers a medical travel support benefit for specific conditions and procedures. Pre-authorization is required.

Note: This program differs from the original airfare reimbursement benefit (for care that is not available locally). Refer to the UA Benefits Travel for Heatlh Care page for more information.
R 

Relocation Allowance Request Form

Electronic Form

To request a relocation allowance.

Retirement Plan Decision Guide

PDF

Guide to retirement plan elections

Retirement Plan Election Form
(TRS/PERS/ORP)

PDF

For employees to elect their participation in TRS, PERS, or ORP based on the employee's retirement plan eligibility. Refer to the appropriate "Retirement Plan Options" documents below.

Retirement Plan Options for Regular Faculty & Academic Officers / Senior Administrators

Decision Tree (PDF)
Notification Form (PDF)

Retirement plan decision tree and notification form for regular faculty and academic officers / senior administrators.

Retirement Plan Options for Non-Academic Officers / Senior Administrators

Decision Tree (PDF)
Notification Form (PDF)

Retirement plan decision tree and notification form for non-academic officers / senior administrators.

Retirement Plan Options for Regular Staff

Decision Tree (PDF)
Notification Form (PDF)

Retirement plan decision tree and notification form for regular staff.
 
S 

Salary Advance Request Form

PDF

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 Exemption Letter & Form for Temporary Employees / Rehired Retirees

Enterable PDF

Letter and form for rehired retirees in a temporary staff or adjunct faculty position to designate their eligibility for retirement benefits and exemption from Social Security withholding.**

**Employees who are exempt from withholding must also complete Form SSA-1945: "Statement Concerning Your Employment in a Job Not Covered by Social Security" Enterable PDF (SSA Site)

State Tax Withholding Certificate List

PDF

List of links to each state's tax withholding certificate form for employees working outside the state of Alaska. For detailed instructions, refer to the Work Activity Outside of Alaska procedures.

Student Enrollment Verification/Dependent Health Care Eligibility

PDF, Enterable PDF

To verify student enrollment and/or to notify employees of dependent (child) health care coverage eligibility.

Student Employee Waiver Form

PDF

For student employees to request a waiver of UA Student Employment policies (e.g. minimum GPA, weekly work hours limit).

Student Status Verification for Eligible Employment

PDF, Enterable PDF

For students to verify/affirm their eligiblity for UA employment.

System Termination Form

PDF, Enterable PDF

To document termination of employment.

System Termination - Employee Exit Letter

PDF, Enterable PDF

Exit letter template for the department to complete/provide to an employee upon their termination, if the employee is not notified of the termination by email via the Termination Workflow process.

(System) Termination - Supervisor Notification of Employee Termination

PDF

Letter template for the department to provide to the supervisor of a terminating employee, if the supervisor is not notified of the termination by email via the Termination Workflow process.
 
T 
Tax Forms Tax form and contact information for employees.

Tax Treaty Withholding Summary - Accounts Payable - CY2016

PDF

Summary of tax withholding for nonresident aliens per tax treaty.

Tax Treaty Summary - Compensation-Related - CY2016

PDF

Summary of tax treaty requirements related to nonresident alien employee compensation.

Tax Treaty Summary - Scholarship and Fellowship-Related - CY2016

PDF

Summary of tax treaty requirements related to nonresident alien scholarships and fellowships.

TDA Salary Reduction Agreement Form - 2021

Form

To establish or change contributions to a tax deferred annuity for calendar year 2021.

Telecommuting Agreement (Within Alaska)

Electronic form

Agreement for employees who will be working remotely within the State of Alaska.

(System) Termination - Employee Exit Letter

PDF, Enterable PDF

Exit letter template for the department to complete/provide to an employee upon their termination, if the employee is not notified of the termination by email via the Termination Workflow process.

(System) Termination - Supervisor Notification of Employee Termination

PDF

Letter template for the department to provide to the supervisor of a terminating employee, if the supervisor is not notified of the termination by email via the Termination Workflow process.

TIAA Online Enrollment Guide

PDF

TIAA-CREF enrollment instructions on opening a retirement account online.

TIAA Transfer/Rollover/
Exchange Authorization Form

PDF

To authorize the rollover, transfer, or exchange of funds from another financial institution to your TIAA-CREF employer-sponsored plan(s).

Time Sheet - Exempt

PDF, Enterable PDF

For exempt (salaried) employees to report leave hours and percent of labor distribution.

Time Sheet - Non-Exempt

PDF, Enterable PDF

For non-exempt (hourly) employees to report daily hours worked and leave hours taken.

TRS / PERS Forms & Brochures

External site

The State of Alaska Division of Retirement & Benefits forms and brochures page for the Public Employees Retirement System (PERS) and Teachers Retirement System (TRS).

Tuition Waiver Request - Employee / Adjunct Faculty

PDF | Enterable PDF

For eligible employees/adjunct faculty to request a waiver of tuition for UA courses and/or fees for UA-approved non-credit courses (listed on the UA Training & Development site).

Tuition Waiver Request - Spouse or Dependent Child

PDF | Enterable PDF

For eligible employees/adjunct faculty to request a waiver of tuition for UA courses for the employee's spouse, FIP, or dependent child.

Tuition Waiver Request - Senior Citizens

PDF | Enterable PDF

For senior citizens to request a waiver of tuition for UA courses.
 
U 

UA Supplemental Life Evidence of Insurability (EOI) Form - FY17

Enterable PDF

Employees electing more than $200,000 in supplemental life coverage are required to complete the Securian Group Life Insurance Evidence of Insurability (EOI) form and submit it directly to Securian Life (via fax or mail - refer to page 3 of document).

Only use the Securian form if you:
- are a new employee hired on or after 7/1/16
- experience a major life event on or after 7/1/16

UA Wellness Program Rebate - Healthyroads Biometric Screening Results Forms

UA Wellness Program

For employees (existing employee or newly covered employee or spouse/FIP under the UA health plan) to submit biometric results from their health care provider to Healthyroads as part of the UA Wellness Program.

Forms, program dates, rebate guidelines, and additional links are available on the Benefits UA Wellness Program page.

UA Approved Non-Credit Courses

UA Training & Development site

UA approved non-credit courses that qualify for the UA employee education benefit.

UA Approved Certified Public Manager (CPM) Courses

UA Training & Development site

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

UA Computer Account Request Form

UAA | UAF | UAS | SW

Campus form or site for employee to request access to UA domains, email, Blackboard, VPN, etc.

UA Computer Administrative Access Request Form

UAA | UAF | UAS | SW
Campus form or site for employee to request access to specific HR security classes for Oracle, Banner applications, databases, Vista Plus, etc.

UAFT Union Sick Leave Bank - Application for Withdrawal

UA Labor Relations site

For UAFT employees to request withdrawal of sick leave from the UAFT Union Sick Leave Bank.

UAFT Union Sick Leave Bank - Usage Procedures

UA Labor Relations site

Usage procedures for a UAFT employee to request leave from the UAFT Union Sick Leave Bank.

UAFT Service Fee Deduction Form

UA Labor Relations site

To initiate a payroll deduction for UAFT union service fees.

UAFT Service Fee Revocation Form

UA Labor Relations site

To stop a payroll deduction for UAFT union service fees.

United Academics Adjuncts AAUP/AFT Dues or Agency Fee Deduction Form

UA Labor Relations site

To initiate payroll deductions for United Academics Adjuncts union dues or agency fees.

United Academics Dues or Agency Fee Deduction Form

UA Labor Relations site

To initiate payroll deductions for United Academics union dues or agency fees.

United Academics Dues or Agency Fee Revocation Form

UA Labor Relations site

To stop payroll deductions for United Academics union dues or agency fees.

United Academics Faculty - Ethics Act Compliance Regarding "Works"

PDF

Summary of UNAC faculty "Works" compliance guidance.
 
V 

Visa Classifications

PDF

Listing of visa classifications, eligibility, and benefits for nonresident aliens.

Visa Waiver Program

PDF

Document detailing the visa waiver program (VWP) and qualifying countries.

Void Adjustment Form

PDF, Enterable PDF

For Payroll offices to document a void of a payroll payment (HR use only).

Voluntary Reduction Request Form - Exempt Employees

PDF

For exempt staff to request a voluntary reduction to their job assignment during the current fiscal year.

Contact Human Resources for additional details and assistance.

Voluntary Reduction Request Form - Non-Exempt Employees

PDF

For non-exempt staff to request a voluntary reduction to their job assignment during the current fiscal year.

Contact Human Resources for additional details and assistance.

 
W

W-4 Form

Online W-4

To declare your federal income tax withholding status for the calendar year. Additional resources for UA employees are available on the W-4 Information page.

W-9 Form

Enterable PDF
(IRS site)

To request a Taxpayer Identification Number from the IRS.

 

For help with job, benefits, and pay-related questions, please contact your campus Human Resources office.

To report any issues with this web page, contact ua-syhr@alaska.edu.

 
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