new hire package - pt employees · 2 days ago · checklist for part-time new hires . 3/2019 -...

1/2020

New Hire Forms Package Part-time Employees

3/2019

New Hire Package Data Form

Human Resources Administrators must complete the information on this page of the New Hire Package.

The information entered on this page will be applied to the remaining forms in the package. This will

allow the HR Administrator to provide the new employee with a package of forms that have been pre-

filled with the data provided. This package can be saved but because of the sensitive nature of the

information it is recommended that you delete the package once completed. Print the forms package

when the data below is completed. Provide a copy of the printed documents to the new employee and

instruct them to complete and return the forms. The completed hire package must be forwarded to the

following address:

DNR Office of Human Resources

#2 Martin Luther King, Jr. Drive, S.E.

Suite 1258 East Tower

Atlanta, Georgia 30334

Effective Date (MM/DD/YY) Month Day Year

Full Name (First Middle Last)

First Name

Middle Initial

Middle Name

Last Name

Home Address

Apartment #

City

State

ZIP Code

County of Residence

Home Phone

Cell Phone

Email Address

Gender

Social Security Number - -Date of Birth Month Day Year

Employee ID (if known)

Division

CHECKLIST FOR PART-TIME NEW HIRES

3/2019 - Checklist - Page 1

Employee Name: Effective Date of Hire:

/ /

The DNR Division HR Representative must complete and forward this checklist to the Office of Human Resources with the new hire package documents.

Form Name Instructions Completed

Essential TeamWorks Entry Forms

Personnel Action Request form (PAR)

Do not complete this form if you have previously completed and forwarded a PAR to OHR as part of the recommendation package.

Personnel Action Instructions Use to properly complete the PAR and discard. DO NOT FORWARD TO OHR.

Instructions for Form I-9 Give to employee. DO NOT FORWARD TO OHR.

Form I-9, Employment Eligibility Verification Form

Section 1 of the form was completed on the first day of employment.

Employee signed the form on page 1.

Documentation is listed on page 2 of the I-9 form and was presented within 3 days of the first day of employment.

Identity and employment eligibility documentation is attached.

Local site manager has reviewed the I-9 and employment/eligibility documents and has signed the I-9 form.

This form is completed and is part of the package forwarded to OHR.

Personal Information Form Employee has completed this form and it is part of the package forwarded to OHR. Emergency Contact Form Employee has completed this form and it is part of the package forwarded to OHR. Form W-4 Employee has completed this form and it is part of the package forwarded to OHR.

DO NOT FORWARD INSTRUCTION PAGES TO OHR.

Form G-4 Employee has completed this form and it is part of the package forwarded to OHR. DO NOT FORWARD INSTRUCTION PAGES TO OHR.

Employment Forms

DNR Application for Employment

Do not complete this form if you have previously completed and forwarded an Employment Application to OHR as part of the recommendation package.

Direct Deposit Notice Give a copy to the employee so they can set up direct deposit. The original signed version of the form is part of the package forwarded to OHR. DO NOT SEND A VOIDED CHECK TO OHR.

Wage Beneficiary Form Employee has completed this form and it is part of the package forwarded to OHR. State Security Questionnaire/Loyalty Oath

Employee has completed this form and it is part of the package forwarded to OHR.

Selective Service Status Form If the employee is male or female they must complete the form. Do NOT allow a male employee to begin work without proof of registration with the Selective Service. Include a copy of the selected documentation and attach it to the Selective Service Status Form.

Human Resources and Administrative Policy Statement

Give to employee. DO NOT FORWARD TO OHR.

DNR Acknowledgement Statements

Employee has completed this form and it is part of the package forwarded to OHR. Give a copy to the employee.

Driver Acknowledgement Form For those who will be driving on State of Georgia business. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

Harassment Training Video Acknowledgment Statement

I have provided a copy of the sexual harassment Video Acknowledgement Statement to the employee so that they can view the video.

Request for Approval of Secondary Employment

For employees with Secondary Employment. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

CHECKLIST FOR PART-TIME NEW HIRES

3/2019 - Checklist - Page 2

Health Insurance Marketplace Coverage Notice.

Employee has completed this form and it is part of the package forwarded to OHR.

New Health Insurance Marketplace Coverage and Options

Give to employee. DO NOT FORWARD TO OHR.

Social Security (not covered) Employee has completed this form and it is part of the package forwarded to OHR. Rehired Retiree Forms

Rehired Retiree Acknowledgment

This form is only for rehired retirees. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

Rehired Retiree Reporting Form - ERS

This form is only for rehired retirees of the ERS. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

Rehired Retiree Reporting Form – LRS

This form is only for rehired retirees of the LRS. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

Rehired Retiree Reporting Form - PSERS

This form is only for rehired retirees of the PSERS. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

Rehired Retiree Reporting Form – TRS

This form is only for rehired retirees of the TRS. DO NOT FORWARD TO OHR IF NOT APPLICABLE.

Other Forms/Issues

Background Consent/Results A completed copy of the Consent for Pre-employment Background Check Form (HR SOP #101, Attachment #6) or the results of the Criminal Background check must be Included.

Acknowledgment of Drug Testing

A signed copy of the Acknowledgement of Drug Testing form #3, HR SOP #201. Include only if the position is designated in TeamWorks as requiring pre-employment Drug testing.

Department Owned Housing Forms

A copy of Attachment #1, 2 and/or 4 of HR SOP #905, Department Owned Housing, must be included if applicable

New Employee Orientation I have provided the employee a copy of, or access to the New Employee Orientation PowerPoint located on the agency intranet at https://dnrintranet.org/hr/orientation_for_new_employees I have discussed the orientation information and answered any questions.

Red Cross Lifesaving Card Include a copy of the Lifesaving Card if the applicant is hired as a Lifeguard. Document copies Documents in the new hire package forwarded to OHR are one-sided copies as I

am aware that some of these documents are separated into multiple folders at the central office.

Name of individual completing checklist:

Phone # Email Address

https://dnrintranet.org/hr/orientation_for_new_employees

Personnel/Position Action Request Form (Revised 1/2020) Section 1: Employee Information First Name:

Middle Name

Last Name:

Emp ID #: SS#: - -

SS# for new hires only Ethnic Group - Gender: - DOB / /

Section 2: Personnel Action Codes/Description Action Code: Reason Code: Description of Action/Reason (See Action Reason Code Manual) 1.

-

2.

-

3.

-

Effective Date:

/ /20

The position is: Full-time Part-time:

Complete the information below for Part-time positions only. If the position is Full-time go to Section 3) If the personnel action is for a part-time hire or rehire which one of the following three statements apply to the position:

1. The position is a 29-hour limited position. (The incumbent will be limited to a maximum of 29 hours worked per week.) 2. The position is Seasonal. (Employee may work 30 or more hours/ week but employment will be limited to 168 calendar days or less.) 3. The position is a “co-op”. (Employee is enrolled as a student & may work 30 or more hrs/wk if they remain enrolled in a work/study program.)

I have informed the employee of the limits of his/her employment listed in #1, #2 or #3 above. I have verified that the hire has not worked for the State of Georgia in the past 13 weeks I have verified that the hire has worked for the State of Georgia in the past 13 weeks and I have obtained permission from the Human Resources Director to start the employee to work. Name: Signature: _______________________________________________________________________

Section 3: Personnel Action FROM: TO: Position # Classified

Indicator Unclassified Position # Classified

Indicator Unclassified

Job Code

Job Title Job Code Job Title

Department ID

462 Department Name

Department ID

462 Department Name

ZIP Code County Code & Name

- ZIP Code County Code & Name

-

Mail Drop ID 462- Reports To Position #

Mail Drop ID 462- Reports To Position #

Pay Rate & Frequency

$ . / - Pay Grade Pay Rate & Frequency- Pay % chg.

$ . / -

Pay Grade

% change

Section 4: Supporting Documents/Information (include documents below and other documents as necessary) Documents supporting a recommendation or hire:

Recommendation Package (See HR SOP #101 for requirements)

FT/PT or POST Hire Package See link for additional info http://dnrintranet.org/hr/hiring_packages

Documents supporting a separation: Resignation/Dismissal letter DOL-800 Separation Notice Final Clearance Form Final timesheet (PT employees) Retirement refund application Leave verified and entered Rehire not recommended - attach

supporting documentation. Notify HR Dir. Last day in pay status / /20 http://dnrnet.dnr.state.ga.us/separations

Documents supporting leave: FML Forms (See HR SOP #608) Return to Work Forms (See HR

SOP #508) LWOP Request Expected Return Date: / /

Regular Short-term Contingent Military or Family.

Actual Return Date: / /

Document Supporting a Job Change, Promotion, Demotion, *Pay increase:

Justification memo * Description of duties Organization chart (before and after) Performance plan Position Information Form

See link for additional info. http://dnrintranet.org/hr/position-action-request

Section 5: Comments List reason for request and any information applicable to the personnel/position action attached additional information as needed. Section 6: Signatures: Completed By:

Date: / /20

Phone #: - -

Email Address:

Additional Signature: Date: / /20

DNR HR Director Signature: Date: / /20

Additional Signature: Date: / /20

Appointing Authority Signature:

Date: / /20

Section 7: Office of Human Resources use only:

Receipt of PAR Received by:_______ Date:_____________ Logged by :_______ Date:_____________

Authorization / Qualifications

Everify Completed by:______ Date:___________________ Person Meets job Minimum Qualifications:

YES NO Minimum Qualifications Reviewed by: ___________ Date: _________________

FLSA Code

Nonexempt Executive Exempt Administrative Exempt Professional Exempt Computer Exempt Other Exempt Highly Compensated

Code assigned by: _________ Date: ___________________

Drug Test Indicator Code

N - None A – P.O.S.T. Certified B – Commercial Drivers’ License P – Pre-employment C – Agency Discretion

50%,Pilots&Mechanics G – US Coast Guard

Code assigned by: ___________________ Date: ______________________________

Field Notification / Entry

Field Notified by: ___________ Date: ____________________ PAR entered by: ___________ Date: ____________________

Personnel/Position Action Request Instructions (Revised 3/2019) General information: The DNR Personnel/Position Action Request form (PAR) is to be used to request any personnel or position action (i.e. changes in pay, supplements, promotions, demotions, data changes, etc). The PAR is to be used for actions affecting hourly and full time employees and positions. Use the Tab key to navigate through the form. The cursor will move from one entry field to the next each time the user hits the Tab key. The form is formatted to include limited data fields, drop-down boxes and check boxes. Some data fields are limited to allow for a specific # of characters that correspond to the required data for that field. Drop down boxes will appear when the users tabs to some entry fields. Drop down boxes are indicated by a down arrow on the right of the entry field. Clicking on the down arrow allows the user to select from a list of appropriate options for entry into that particular field. Check boxes simply allow for an ‘X’ to be entered when the user clicks on the field.

Section 1: Employee Information Name: Enter the employee’s name as it appears in TeamWorks or if it is a new hire list the employee’s name as it is to be entered into TeamWorks. If the position is vacant enter vacant in the field designated for employee name. Employee ID #: Enter the complete 8-digit ID #. If the employee is a new hire no ID number is required. The ID # for new hires will be assigned by HR. SS#: Enter the employee’s Social Security #. (used for new hires only) Ethnic Group: Click on the drop down list provided and enter the appropriate ethnic group from the selection provided. Gender: Click on the drop down list provided and enter the appropriate gender from the selection provided. DOB: Enter the employee’s date of birth.

Section 2: Personnel Action/Reason Codes TeamWorks requires that an action code and a reason code be entered into the system for each personnel action processed. The PAR form provides fields for three action/reason codes to be entered. These codes are used to describe the type of personnel or position action being recorded. Selection of the correct code(s) is essential to accomplishing the personnel action. Use the TeamWorks HCM System Action Reason Code Manual located in the HR section of the DNR Intranet at: https://dnrintranet.org/hr/position-action-request to select the appropriate codes. The manual contains definitions for each action reason code. Action Code: Select the appropriate action code from the drop-down list accessed by clicking on the down arrow on the right side of the action code field. Reason Code: Enter the appropriate reason code from the manual listed above. The reason code field does not contain a drop down list of reason codes due to limitations built into MS Word. Description of Action/Reason: Enter the long description of the action reason as provided in the Action Reason Code Manual. Effective Date: Enter the effective date of the action. This date is the date that the requestor wants the personnel action to be effective. The date must be a future date and should be the 1st or the 16th of a month. PT or FT: Select PT (Part-time or FT Full-time) from the drop down list provided. PT Seasonal or 29 hour limited or “co-op”: If the position is a part time hire/rehire check one of the boxes indicating if the position is seasonal and limited to 168 calendar days of employment, limited to a maximum of 29 hour worked per week, or a co-op and may work more than if in a work/study program. Verification and approval of the rehire: Verify that the employee has or has not worked for the State of Georgia in the past 13 weeks. If they have worked for the SOG in the past 13 weeks verify that you have obtained permission from the Human Resources Director for the employee to start work.

Section 3: Personnel Action This section contains two ‘sides’ The left side of the page is the FROM side and the Right side of the page is the TO side. The data fields are identical on both sides however the FROM side should contain current position data and the TO side should reflect changes to be made in position data as a result of the PAR being processed or data of the position the employee is being moved to. All data required in Personnel Action section of the form may be obtained via TeamWorks and/or the PAR reference documents located on the DNR Intranet at https://dnrintranet.org/hr/position-action-request Complete all fields in the TO and FROM sections. Position #: Enter the position number of the position requiring action. Status: Select the Status of the position from the drop down list or from Position Data 3 screen in TeamWorks C (Classified) or U (Unclassified) Job Code: Enter the “old” job code as provided on the DNR Salaried Job Code Reference Document at https://dnrintranet.org/hr/position-action-request Job Title: Enter the “new” job title as provided on the DNR Salaried Job Code Reference Document at https://dnrintranet.org/hr/position-action-request Department ID: Enter the department number as provided PAR reference Document or in TeamWorks. Department Name: Enter the Department Name of the department of the affected position. ZIP code: Enter the ZIP Code of the work location of the affected position. County Code: Enter the County Code of the county of the work location of the affected position. Maildrop ID: Enter the maildrop ID assigned to the work location. Reports To Position #: Enter the position number of the supervisor of the affected position. Pay Rate& Frequency and Pay % change: Enter the Pay Rate of the incumbent. Select the Pay Frequency from the drop down list. The TO side of the action includes a field for % change. Enter the percentage amount of the change to be made to the employee’s pay if creating a pay action. Pay Grade: Enter the pay grade of the position.

Section 4: Supporting documentation Include appropriate documentation to support the personnel action request. Enter an x in the applicable check box to indicate attached documentation.

Section 5 Comments Enter any comments applicable to the personnel action requested.

Section 6: Signatures Completed by: Enter the name of the employee who completed the form. Phone Number: Enter the phone # of the employee who completed the form. Appointing Authority Signature: The AA is the DNR Commissioner or for EPD PARs it is the Director of EPD. HR Director Signature: Signature of the Director of Human Resources. Additional Signature: Signature of any other authorizing individual. Date: Enter date signed. ROUTE THE COMPLETED PAR TO: THE DNR OFFICE OF HUMAN RESOURCES #2 MLK JR. DR S.E. SUITE 1258 ATLANTA GEORGIA 30334

Section 7: Office of Human Resources Use Only Info. This section will be completed by representatives of the DNR – Office of Human Resources.

http://sao.georgia.gov/documents/action-reason-codes-manual

PERSONAL INFORMATION FORM

Last Name First Name Middle Name

Social Security # - - Contact Information

Home Phone

- - Mobile Phone

- - Email Address

Address

Home Street Address

Apartment #

City State Zip Code

County

☐ Check box and leave information below blank if mailing address is same as home address.

Mailing Address

Address

Apartment #

City State Zip Code

County

Birth and Gender Information

Date of Birth / /

Birth State Birth Country

Gender: ☐ Male ☐ Female

Ethnic Group Marital Status

☐ American Indian / Alaska Native ☐ Common-Law

☐ Asian ☐ Divorced

☐ Black / African American ☐ Head of Household

☐ Hispanic / Latino ☐ Married

☐ Not Specified ☐ Separated

☐ Native Hawaiian / Other Pacific Islander ☐ Single

☐ White ☐ Widowed

☐ Unknown

☐ Dissolved Declaration Lost Civil Partner

Employee ID # 3/2019

PERSONAL INFORMATION FORM

Highest Education Level Language (check only if fluent in language other than English)

☐ Not Indicated ☐ Canadian French

☐ Less Than High School Graduate ☐ Danish

☐ High School Graduate or Equivalent ☐ Dutch

☐ Some College ☐ French

☐ Technical School ☐ German

☐ 2 Year College Degree ☐ Greek

☐ Bachelor’s Degree ☐ International English

☐ Some Graduate School ☐ Italian

☐ Master’s Degree ☐ Japanese

☐ Doctorate (Academic) ☐ Korean

☐ Doctorate (Professional) ☐ Portuguese

☐ Post Doctorate ☐ Simplified Chinese

☐ Specialist in Education ☐ Spanish

☐ Swedish

☐ Traditional Chinese

☐ Thai

Military Service Citizenship Status

☐ Not a Veteran ☐ Alien – Permanent

☐ Active Reserve ☐ Alien – Temporary

☐ Inactive Reserve ☐ Native (Born in the United States)

☐ Post-Vietnam-Era Veteran ☐ Naturalized

☐ Pre-Vietnam-Era Veteran

☐ Retired Military

☐ Vietnam-Era Veteran

Employee ID # 3/2019

EMERGENCY CONTACT FORM

Employee ID# _____________________ 3/2019

Employee Information

Employee Last Name

Employee First Name

Employee Middle Name

First Emergency Contact

Contact Name

Relationship to Contact

Same address as employee Same home phone as employee

Home Street Address Apt. #

City State Zip Code

County

Telephone (Home) Business Mobile

Second Emergency Contact

Contact Name




City State Zip Code

County


Third Emergency Contact

Contact Name




City State Zip Code

County


GEORGIA DEPARTMENT OF NATURAL RESOURCES

APPLICATION FOR EMPLOYMENT An Equal Opportunity Employer

Daytime Telephone Number

- - E-Mail Address

Last Name

First Name

Middle Initial

Mailing Address

Apartment #

City

State

Zip Code

County

EMPLOYMENT ELIGIBILITY:

To be employed by the State of Georgia you must meet certain State and Federal employment eligibility requirements.

These include (but are not limited to) United States citizenship or authorization to work in this country, positive rehire status if previously employed by the State, and no disqualifying criminal convictions (for some jobs).

Please answer the following questions.

1. Are you 18 years of age or older? Yes No

2. Are you a current State of Georgia Employee?

Yes No

3. Have you been dismissed from a State of Georgia government position?

Yes No

TYPE OF WORK:

Specific Job Title Sought Position # or Job #

SOURCE:

Please indicate how you heard about this job: Agency Website Broadcast Career Fair Direct Mail Job Board Magazine & Trade Publications Newspapers Other Professional Association Referral Social Network Service Talent Exchange Team Georgia Careers University / Campus Recruiting Unsolicited

DNR 04-2015 1



EDUCATION:

High School Graduate or Equivalent (GED)? Yes No

College / Technical School Program

Institution City/State Major Hours Minor Hours Type of Degree

Date Degree Completed

/

/

/ /

LICENSES AND CERTIFICATIONS:

Type of License/Certificate License/Certificate Number Expiration

(Mo/Yr) Specialization/ Endorsements

/

/

/

/

COMPUTER EXPERIENCE:

Describe your computer skills (ex. Microsoft Word, Excel, PeopleSoft, Internet, etc…)

WORK HISTORY:

Describe your work history below beginning with your current or most recent job.

If you need more space, print out the supplemental work history page and attach it to the application.

You may attach a resume to supplement your work history information.

Current or Last Employer

Job Title

Start Date (mo/day/year)

End Date (mo/day/year)

Hours per Week

Supervisor’s Name

Supervisor’s Title

Your Salary

Supervisor’s Phone Number

( ) - May we contact the Supervisor?

Reason for Leaving

# and types of employees you supervised (if applicable)

Describe in detail your job duties

DNR 04-2015 2



Employer

Job Title



Hours per Week

Supervisor’s Name


Your Salary



Reason for Leaving



Employer

Job Title



Hours per Week

Supervisor’s Name


Your Salary



Reason for Leaving



CERTIFICATION: Read carefully before signing and dating. Unsigned applications will not be processed. By signing below, I certify/confirm that my application, resume, and any document enclosed as part of submission for the job is accurate and complete to the best of my knowledge. I understand that state employers will verify the information provided. I also understand that applications submitted electronically, via e-mail or similar media, are not valid unless I enter my name in the signature field below and such action shall constitute an electronic signature. I further understand that omitting or providing false information on this form, or any other subsequent application materials, will be sufficient reason to disqualify me from consideration for employment, or immediate dismissal if I am employed. Signature: Date: / /

DNR 04-2015 3



EQUAL EMPLOYMENT OPPORTUNITY SELF IDENTIFICATION FORM

The State of Georgia provides equal employment opportunities (EEO) to all employees and applicants for employment without regards to race, color, religion, sex, national origin, age, disability, or genetics. In addition to federal law requirements, the State of Georgia complies with applicable state laws governing nondiscrimination in employment in every location in which the State of Georgia has facilities. This applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.

The information you provide in this section is optional. The information will be used by state agencies to comply with Federal guidelines for monitoring the equal opportunity efforts of the State of Georgia and for no other reason. Your answers will not be used against you in any way.

Race/Ethnicity

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Multiracial Native Hawaiian or Other Pacific Islander White I do not wish to provide this information

Gender

Male Female I do not wish to provide this information

Veteran

The laws of the State of Georgia afford some degree of preference to veterans in certain initial employment decisions. If you believe you belong to any of the categories of veterans listed below and have not been dishonorably discharged, please indicate by checking the appropriate box below. A DD214 and/or other supporting documents will be required.

US Armed Forces Veteran Disabled Veteran (at least 10% disability) Disabled Veteran’s Spouse Deceased Veteran’s Widow/Widower

For Agency Use

DNR 04-2015 4

DIRECT DEPOSIT NOTICE

The State of Georgia requires employees to have their pay check direct deposited. DNR requires employees to set up and maintain their direct deposit in Employee Self Service. I understand that it is my responsibility to access Employee Self Service in TeamWorks at https://hcm.teamworks.georgia.gov/ and follow the path as shown below (Main Menu > Self Service > Payroll and Compensation > Direct Deposit):

I will access Employee Self Service in TeamWorks to authorize the Department of Natural Resources to deposit my net pay directly into my account. The Department of Natural Resources is also authorized to adjust any over/under deposit, which it has caused to be made to my account. I recognize that the Deposit of my net pay shall be made by electronic means. I further understand that if I change banks or accounts that I am responsible for changing the information via TeamWorks Employee Self Service. I understand that detailed instruction regarding accessing TeamWorks and Employee Self Service is located in the new employee orientation documents at https://dnrintranet.org/hr/orientation_for_new_employees. I understand that although I will request Direct Deposit, certain checks will not be deposited into my account but will be provided to me as paper checks. These checks are:

My first pay check; and

Any check that is not run in the normal pay run cycle. My last payroll check and annual leave check paid to me upon my termination from the Department may be a paper check.

Contact the DNR Payroll Office at 404-657-1706 if you have questions regarding Direct Deposit.

DO NOT SEND VOIDED CHECK TO OHR.

Date Division

Employee’s Printed Name

Employee’s Signature

EID: _____________________ 3/2020

BENEFICIARY DESIGNATION FORM

1/2020

Employee Information Please print all information except your signature

Employee’s Name

Social Security # (new hires only) - -

Employee ID

Employee Signature Date

The following information is presented to help you choose and properly designate a recipient

for any OUTSTANDING WAGES in the event of your death.

• A designated beneficiary will be the primary recipient of any outstanding wages over any other individual.

• Where the designated beneficiary is under a legal incapacity that will act to prevent the beneficiary from directly receiving the outstanding wages, please indicate in the appropriate area, the name and address of the duly qualified guardian of the beneficiary.

• This beneficiary designation is for outstanding wages and will not supersede any beneficiary which you may have designated for your retirement or insurance benefits.

Primary Beneficiary Information If, upon my death, wages or other monies are due me from the State of Georgia, Department of Natural Resources, I hereby authorize all such sums to be paid to the following designated beneficiary.

Beneficiary’s Name SS#

Street Address Apt #

City State Zip Code

Secondary Beneficiary Information If, upon my death, wages or other monies are due me from the State of Georgia, Department of Natural Resources, I hereby authorize all such sums to be paid to the following designated beneficiary. The secondary beneficiary will receive the outstanding wages or other monies only if the primary beneficiary is deceased or waives compensation.

Beneficiary’s Name SS#


City State Zip Code

Guardian Information for Primary Beneficiary If the Beneficiary is a minor the following information must be provided

Guardian’s Name SS#


City State Zip Code

Guardian Information for Secondary Beneficiary If the Beneficiary is a minor the following information must be provided

Guardian’s name SS#


City State Zip Code

Georgia law O.C.G.A 34-7-4 states that in the absence of a beneficiary designated in writing by the employee any outstanding wages will be paid to the surviving spouse. In the absence of a beneficiary designated in writing by the employee and where the employee left no surviving spouse but left a surviving child or minor children, then payment of outstanding wages will be paid to the duly qualified guardian of the minor child or children.

NOTE: It is your responsibility to keep this information updated by contacting the Office of Human Resources to update this form.

STATE SECURITY QUESTIONNAIRE

LOYALTY OATH

NOTICE TO APPLICANTS/EMPLOYEES: The Sedition and Subversive Activities Act of 1953 (Georgia Law 16-11-5 et seq.) requires each applicant/employee to complete and sign, prior to employment in State Government, a questionnaire which is designed to establish that there are no reasonable grounds to believe that he/she is a subversive person. A subversive person is defined as one who commits, advocates, or teaches any act intended to overthrow or destroy the government of the United States or government of the State of Georgia by force or violence, or who is a knowing member of a subversive organization. Georgia Code 45-3-11 requires all employees of the State of Georgia to take an oath that they will support the Constitution of the United States and the Constitution of the State of Georgia. INSTRUCTIONS: All items must be completed on a typewriter or printed in ink. If more space is needed for any item, or explanation, continue under item 10. This questionnaire and loyalty oath will be filed in the employee’s personnel file in the employing agency. The employee may request that a copy be executed for his/her personal files.

1. LIST FULL NAME (ALSO INCLUDE MAIDEN NAME, NAMES OF FORMER MARRIAGES, FORMER NAMES CHANGED LEGALLY OR OTHERWISE, ALIASES, NICKNAMES AND THE DATES USED).

LAST NAME FIRST NAME MIDDLE NAME

PHONE NO. ( )

MAIDEN NAME DATES USED NICKNAMES DATES USED

OTHER NAMES, INCLUDING ALIASES & FORMER MARRIAGES

DATES USED DATES USED

DATES USED DATES USED

2. ADDRESS (No and Street of Residence) APT NO CITY STATE COUNTY ZIP CODE

3. DATE OF BIRTH / /

U.S. CITIZEN ____Yes ____No (NATIONALITY______________________________________)

RACE

SEX

4. Are you now or have you been within the last ten (10) years a member of any organization which to your knowledge at the time of membership advocates or has as one of its objectives, the overthrow of the government of the United States or of the government of the State of Georgia by force or violence? ___Yes ___No. If “Yes”, state the name of the organization and your past and present membership status including any offices held therein.

NOTE: If the answer to the above question is “Yes” and the employing authority deems further inquiry necessary, you will be notified of such determination. No action adverse to your application will be taken because of an affirmative answer until after such an inquiry, with notice to you and an opportunity for you to present evidence, and only if the result of such brings your application within the prohibition within the Sedition and Subversive Activities Act of 1953.

5. LIST CHRONOLOGICALLY ALL OF YOUR PREVIOUS RESIDENCES FOR THE PAST TEN YEARS:

DATES STREET CITY STATE

From To

6. LIST NAMES AND ADDRESSES OF THE FOLLOWING:

SPOUSE (MAIDEN NAME)

ADDRESS

FATHER ADDRESS

MOTHER ADDRESS

7. MILITARY SERVICE (Past or Present)

SERIAL NUMBER BRANCH ACTIVE SERVICE ACTIVE OR INACTIVE RESERVE DISCHARGED Honorably ( ) Dishonorably ( ) Other ( ) If Discharge other than Honorable, explain in item 10.

From To From To

8. Have you ever been convicted by Federal, State, or other law-enforcement authorities, for any violation of any Federal law, State law, County or Municipal law, regulation, or ordinance? (Do not include anything that happened before your sixteenth birthday. Do not include minor traffic violations for which a fine of $35.00 or less was imposed. All other convictions must be included even if they are pardoned.) ___Yes ___No. If the answer is “Yes”, state the reason convicted, the date convicted, and the place where convicted.

CHARGE ON WHICH CONVICTED DATE CONVICTED NAME OF COURT & PLACE WHERE CONVICTED PARDONED (yes or no)

9. Are there any charges now pending against you by Federal, State, or other law-enforcement authorities, for any violation of any Federal law, State law, County or Municipal law, regulation or ordinance? (Do not include anything that happened before your sixteenth birthday. Do not include minor traffic violations for which a fined of $35.00 or less would likely be imposed.) ___Yes ___No. If the answer is “Yes”, provide the following information.

VIOLATION CHARGED NAME OF GOVERNMENT NAME OF COURT & LOCATION WHERE PENDING

10. SPACE FOR CONTINUING ANSWERS OR EXPLANATIONS (Show item numbers to which answers or explanations apply. Attach a separate sheet if more space is needed.)

Note: Before signing this form, check all answers and explanations to see that you have answered all questions fully and correctly. This form is to be executed under oath subject to penalties of false swearing as prescribed in Georgia Law 16-10-71 of the Criminal Code of Georgia.

LOYALTY OATH

I, _________________________________________________________________ (Name of Applicant/Employee), a citizen of ___________________and being an employee of the State of Georgia and the recipient of public funds for services rendered as such employee, do hereby solemnly swear and affirm that I will support the Constitution of the United States and the Constitution of the State of Georgia.

AFFIDAVIT OF VERIFICATION Georgia __________________ County Personally appeared before the undersigned officer, duly authorized to administer oaths _____________________________________________________, who, after being duly sworn, deposes and says and declares under penalties of false swearing that he is the person who executed the foregoing instrument; that he has read and completed the same and knows and understands the contents thereof; that the matters stated therein and the answers and information furnished by him in the foregoing questionnaire, and loyalty oath, including any attachments thereto, are true and correct. SWORN TO AND SUBSCRIBED BEFORE ME: . SIGNATURE OF AFFIANT (Applicant/Employee) This day of (month) , (year) . ____________________________________________

PRINT NAME . SIGNATURE OF NOTARY PUBLIC My commission expires .

SELECTIVE SERVICE STATUS FORM

8/2019 - Selective Service Form Page 1

This Page of the Selective Service Status Form is to be completed by all newly hired male and female employees. If you are a male, 18 through 25 years of age, you cannot begin employment with the Department of Natural Resources (DNR) until you present proof of having registered with the Selective Service System or of being exempt from registration. You cannot hold a position with the DNR if proof of Selective Service status is not available. Georgia State law (O.C.G.A 45-20-20) requires all males 18 through 25 years of age to present proof of having registered for the Selective Service System or of being exempt from such registration, prior to employment. Please verify Selective Service status by checking the appropriate statement below and signing your name. You will be required to show documentation to verify your status.

Section 1: Selective Service Status Last Name

First Name

Middle Name

I am a female.

I am under the age of 18 years and am not currently required to register with the Selective Service. (I understand on my 18th birthday, I must register for selective service and provide my Selective Service registration number to the Office of Human Resources.)

I am over the age of 25 years and am not required to register with the Selective Service. My date of Birth is _________/__________/_______________.

I am on active duty with the Armed Forces of the United States other than for training in a Reserve or National Guard Unit. (I understand if I 18 through 25 years of age, I must register for Selective Service if I am released from active duty and must provide my Selective Service number to the Office of Human Resources.)

I am non-immigrant lawfully in the United States and not required to register.

I am a male, 18 through 25 years of age, and have registered with the Selective Service. My Selective Service number is ___________________________.

I have registered with Selective Service within the past six weeks; however, since Selective Service processing may take four to six weeks; I have not yet received my confirmation. I understand that I cannot be eligible for state employment until I show proof of registration. NOTE: DIVISION HR REPRESENTATIVE; THIS PERSON SHOULD NOT START WORK.

I certify that the above information is correct and complete. Employee Signature____________________________________________________ Date______/______/_____________

SELECTIVE SERVICE STATUS FORM

8/2019 - Selective Service Form Page 2

The DNR Representative is to complete the applicable Section 2, or 3, or 4 and sign Section 5.

Section 2: Males Over 25 Years of Age & Females I, the undersigned, certify that I have seen proof that the person named above is either female or a male over 25 years of age. The following document was used to verify the age or sex of this employee: A copy of the document checked below is attached.

Birth Certificate Passport Driver’s License Military I.D. Card

Section 3: Proof of Registration with the Selective Service System for Males, Ages 18 through 25 I, the undersigned, certify that I have seen proof that the male named above is 18 through 25 years of age and has shown me proof of having registered with the Selective Service System. A copy of the Registration Acknowledgment Card is attached. Note: If the applicant did not receive a registration acknowledgment card within 90 days of registering, or if he requires a replacement acknowledgment card, please call Selective Service at 1-847-688-6888. Your call will be answered by an automated voice processing system. Listen carefully to the directions and with the assistance of the applicant, select the option for receiving his own Selective Service number. Selective Service Number: _____________________________. Registration may also be verified on-line at https://www.sss.gov/Registration/Check-a-Registration/Verification-Form.

Section 4: Proof of Being Exempt from Registration with the Selective Service System *Must register within 30 days of release unless already age 26

I, the undersigned, certify that I have seen proof that the person named above is 18 through 25 years of age and has shown me proof of being exempt from registration with the Selective Service System. A chart of who is exempt from registration is at https://www.sss.gov/Portals/0/PDFs/WhoMustRegisterChart.pdf. A copy of the document checked below is attached.

Lawful non-immigrants on current non-immigrant visas. A complete list of acceptable documents may be found at https://www.sss.gov/Portals/0/PDFs/DocumentationList.pdf

Seasonal agricultural worker (H-2A Visas) Active duty military ID * Proof of attending as a Cadet or Midshipmen at the Service Academies or Coast Guard Academy* Proof of attending as a student in Officer Procurement Programs at The Citadel, North Georgia College

and State University, Norwich University, Virginia Military Institute, Texas A&M University, Virginia Polytechnic Institute and State University *

Section 5: Signature

DNR Representative (Print Name)

DNR Representative Signature

Date:

3/2019


Instructions: Read and initial each acknowledgement in the upper right hand of the statement. Complete and sign at the bottom of Page 2.

Human Resources and Administrative Services Standard Operating Procedures initial

The Department of Natural Resources (DNR) Standard Operating Procedures, (SOPs), contain important information pertaining to my employment at the DNR. I understand that the DNR, Human Resources SOPs are contained on the Department intranet site and are available to me at http://dnrintranet.org/hr/standard-operating-procedures. The office of Administrative Services SOPs are contained on the Department intranet site and are available to me at http://dnrintranet.org/ad/standard-operating-procedures.

I understand that I am personally responsible for visiting the intranet site, reading, understanding, being knowledgeable of and complying with the requirements of these procedures. I understand that I should consult my supervisor if I have any questions about the information contained in the SOPs.

I understand DNR may revise, delete and/or add to the SOPs. All such changes will be communicated through official notices. I understand and agree that it is my responsibility to read the official notices and to read, understand and be knowledgeable of procedure revisions. I understand that the information contained at the intranet links above contain the most updated information

and supersedes all prior procedures that provided Human Resources or Administrative Services guidance to DNR employees.

Understanding Concerning the Use of FLSA Compensatory Time initial I acknowledge and agree that as part of the terms and conditions of employment for nonexempt employees with the Department of Natural Resources, I understand that a nonexempt employee may be required to work more than 40 hours in a work week. I further understand that, in lieu of overtime compensation in cash, a nonexempt employee may receive compensatory time off at the rate of one and one-half hours for each hour of employment for which overtime compensation is required by the Fair Labor Standards Act of 1938 (FLSA). I understand that the compensatory time may be preserved, used, or cashed out consistent with the provisions of the FLSA. I understand that all work performed by DNR employees is compensated and no supervisor may authorize work ‘off the clock’. I further understand that I must accurately record time worked and if I work ‘off the clock’ and do not record the time worked, I will be subject to disciplinary action.

Employment At-Will initial I understand that Employment At-Will means that my employment relationship with the Georgia Department of Natural Resources is for an indefinite period of time. As such, I acknowledge that my employment may be terminated at any time, with or without cause, by either the Department or me.

The employment-at-will relationship exists regardless of any Georgia Department of Natural Resources written statements, policies, procedures, documents or any verbal statements to the contrary. No written statements, policies, procedures, document or verbal statement is intended to create an express or implied contract of employment or to guarantee employment for any term.

Page 1 of 2

3/2019


Statewide Sexual Harassment Prevention Policy initial I acknowledge that the Statewide Sexual Harassment Prevention Policy is on the agency intranet as part of the training materials at https://dnrintranet.org/hr/training I have reviewed, and agree to comply with the State of Georgia Statewide Sexual Harassment Prevention Policy. I understand that failure to comply with the Policy could result in disciplinary action up to and including termination of my employment.

Workers Compensation Acknowledgement initial This is to certify that I have been given information about the State Board of Workers’ Compensation, the “Panel of Physicians” and the purpose of these services. I understand that if I am involved in an on-the-job accident and become ill or injured, if emergency treatment is NOT necessary, I must accept the services from a Panel physician. If I obtain medical service from a physician who is not listed with the AMERISYS, INC. managed care organization, I will be responsible for those medical expenses. The AMERISYS, INC. (Panel) Physician may arrange for appropriate consultations, referrals or other specialized medical services, as the nature of the injury requires. If I am dissatisfied with the medical services, I can request one change (without the employer’s permission) to visit a second (different) physician from the AMERISYS, INC. group. However, any further changes require the expressed permission of a Claim Representatives from the Department of Administrative Services, or the State Board of Workers’ Compensation. In the case of an emergency, I may be treated at the nearest emergency room. However, all follow up care must, thereafter, be rendered by a physician designated/selected from the managed care organization (or an AMERISYS, INC. referral). I further understand that I must notify my supervisor as soon as an injury occurs or as soon as I receive care from AMERISYS, INC. regardless of the extent of the injury. Delay in notification can result in denial of payment for medical services rendered. If my claim is accepted as compensable and I have been taken out of work by my authorized treating physician as a result of the injuries sustained then I understand I am entitled to elect to be paid through eligible leave OR receive weekly indemnity benefits through workers’ compensation if I have more than seven days of lost time due to an injury. If I am out of work more than 21 consecutive days due to my injury, I will be paid for the first week. I understand that I am entitled to one independent medical examination by a physician of my choice. However, I must notify DOAS in writing in advance of any independent examination. The cost will be paid by DOAS but no diagnostic procedures performed since the date of my on-the-job injury (and costing in excess of $250.00) can be repeated by my independent physician. I understand that I may be expected to pay for procedures which have not been authorized by DOAS.

My signature below acknowledges that I understand and will comply with the information contained in this document. I am aware that this statement will become part of my official personnel record. I understand that any violation of the policies/procedures referenced above may result in disciplinary action up to and including dismissal from employment.

Date: / / Employee ID:

Division Name:

Employee’s Printed Name:

Employee’s Signature:

Page 2 of 2

https://dnrintranet.org/hr/training

DNR SOP - AdminSOP030 Attachment #1

Page 1 of 1 1/2016

Driver Acknowledgement Form

Before operating a vehicle on department business, employees/volunteers/interns must use this form to certify that they are qualified to safely operate the vehicle. Employees/volunteers/interns that drive on department business, regardless of the frequency, must use this form to recertify annually according to the schedule provided in the SOP. By signing this form, I authorize the retrieval of my driving history and also certify that I am qualified to safely operate a vehicle for department business. I am a (check the box that applies): DNR Employee Volunteer Intern Please initial on each line. I specifically certify the following: I have a valid license for operating the vehicle. Expiration Date: I agree to use vision correction measures while operating this vehicle, if required by my driver’s license. I do not have pending charges, or a conviction within the past 6 months, for any of the following offenses, and I agree to immediately notify my supervisor should I be charged with one or more of these offenses:

Driving Under the Influence Leaving the Scene of an Accident

I agree to notify my supervisor of any changes involving the above initialed items before I operate a vehicle for department business. I agree to notify my supervisor immediately upon License Suspension, Revocation or Expiration. I have reviewed and understand DNR SOP 030, Attachment # 2, Driver Safety Tips.

I have reviewed the driver safety video assigned for this year.

DRIVER’S LICENSE INFORMATION (please print and reflect information exactly as it appears on your driver’s license.) First Name Middle Name Last Name Date of Birth License # State

I have a valid out-of-state Driver’s license and have included a copy of my driver’s history with this acknowledgement form. . Employee/Volunteer/Intern Signature Employee ID # ___ . Division Date

SEXUAL HARASSMENT PREVENTION TRAINING VIDEO ACKNOWLEDGMENT STATEMENT

As per the Statewide Sexual Harassment Prevention Policy issued on March 1, 2019 by the Department of Administrative Services and

the Office of the Inspector General I have viewed the following Sexual Harassment video(s).

Sexual Harassment Prevention for Employees (Modules 1-6) Note: The Employee training video is located on the agency intranet at https://dnrintranet.org/hr/training

Sexual Harassment Prevention for Supervisors/Managers (Modules 1-5) Note: The Office of Human Resources will register you for this course. You will receive an automatic registration email from Team

Georgia Learning, which includes the login credentials and instructions on how to login and launch the online training course.

___________________________________________________________________________________________________

SEXUAL HARASSMENT PREVENTION EMPLOYEE ATTESTATION

Thank you for completing the Sexual Harassment Prevention in the Workplace online training course. Please confirm your

understanding of several key points provided in the online training. By checking each of these statements, you confirm your

understanding of the following key points reviewed in the online training course:

I should not engage in any physical, verbal, or other conduct that is either directed toward an individual or reasonably offensive to

an individual because of his or her sex, including unwanted sexual attention, sexual advances, requests for sexual favors, sexually explicit

comments, or other conduct of an expressed or obviously implied sexual nature.

I should not engage in conduct that is hostile, threatening, derogatory, demeaning, or abusive or intended to insult, embarrass,

belittle, or humiliate an individual because of his or her sex.

I am not to engage in retaliation against anyone for submitting or assisting with submitting a complaint of or reporting sexual

harassment, for participating in a sexual harassment investigation or proceeding, or for otherwise opposing sexual harassment against

the person who submitted the claim.

If I believe I have been subjected to sexual harassment or retaliation in violation of the Statewide Sexual Harassment Prevention

Policy I am strongly encouraged to promptly submit a complaint regarding the incident(s) to my supervisor or manager, division director,

Human Resources or other agency designee or the Office of the State Inspector General if any of the above officials are the alleged

harasser or retaliator, or if I have fear of retaliation by one of the above officials.

If I have witnessed or otherwise have reason to believe that another employee is being or has been subjected to sexual harassment

or retaliation, I am required to promptly report this to one of the Agency officials listed in the previous bullet.

If I am found to have engaged in sexual harassment and/or retaliation in violation of the Statewide Sexual Harassment Prevention

policy,. I will be subject to corrective and/or disciplinary action, up to and including termination of employment.

Please check one of the following boxes:

I am a Part Time Employee or Intern I am a Full Time Employee

Date:

Employee ID:

Division:

Employee’s Printed Name

Employees Signature:

https://dnrintranet.org/hr/training

DNR SOP – HR203 Attachment #1

Retention: Retain in the official personnel file for full-time employees. Retain in local management file for part-time employees.

6/17

Request for Approval of Secondary Employment Employee/Position Information

Name: Employee ID:

Home Address:

Job Title: Full time Part time Division:

Secondary Employment Information

Check Here if Secondary Employment. Check Here if Employment is ‘Extra Duty’ (POST Certified LE employees

only). (See Law Enforcement Division Policy No. S-6, Secondary Employment Policy.)

Secondary Employer:

Type of Business:

Business Address: Work Schedule/Hours:

Supervisor’s Name: Business Phone #:

Description of Job Responsibilities:

Secondary Employment with the State of Georgia

I have a Masters or Doctoral degree Not applicable (Skip this section if you do not have an advanced degree.) Degree held: ____________College/University: My secondary employment is with the State of Georgia and my signature below certifies that I have declined all State health and flexible benefits, Workers Compensation, and retirement benefits associated with my secondary employment position.

I have attached a written request from the chief executive of the secondary employer that identifies why the best interest of the state to obtain my services in lieu of obtaining such services from a person not presently employed by the State of Georgia.

My signature below indicates that I have complied with the Approval for Employees with Advanced Degrees section of SOP HR203, Secondary Employment.

Employee’s Signature: Date:

Notice of Secondary Employment Ending

Check Here if Secondary Employment Has Ended. Date Secondary Employment Ended:

Secondary Employment Recommendation My signature below indicates that I have reviewed the criteria for secondary employment in SOP HR203, Secondary Employment, and based on the criteria, reflects my recommendation regarding the secondary employment of this employee.

Approve Deny

Signature of Manager/Supervisor: Date:

Approve Deny

Signature of Division Director: Date:

Approve Deny

Signature of DNR HR Director: Date:

HEALTH INSURANCE MARKETPLACE HEALTH CARE COVERAGE NOTICE

3/2019

The Federal Patient Protection and Affordable Care Act (ACA), requires employers to notify employees of the ability to seek health care coverage through the Health Insurance Marketplace established by the Federal Government.

Department of Natural Resources (DNR) meets this requirement by providing you with the attached standard notice form issued by the Federal Office of Management and Budget as part of the DNR new hire package.

Information on the operation of the Marketplace is contained in this notice. Upon receipt of this notice, you must complete the information required below. This completed document will become part of your file in the Office of Human Resources.


Full time Part time Check one

Employee Name (print Name)

Employee Signature

Date

Form SSA-1945 (01-2013) Destroy Prior Editions

Social Security Administration

Statement Concerning Your Employment in a Job Not Covered by Social Security

Employee Name Employee ID#

Employer Name Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.”

For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits.

Signature of Employee Date

Form SSA-1945 (01-2013)

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

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:

• Give the statement to the employee prior to the start of employment;

• Get the employee’s signature on the form; and

• Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at [email protected] or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

REHIRED RETIREE ACKNOWLEDGMENT

3/2019

This forms is to be completed only if the new DNR employee is a retired member of one of the State of Georgia

Retirement systems listed below:

Rehired Retiree Information

I certify that I am a retired member of the following State of Georgia Retirement System:

Employees Retirement System (ERS)

Judicial Retirement System (JRS)

Legislative Retirement System (LRS)

Public School Employees Retirement System (PSERS)

Teachers Retirement System (TRS)

Employee Name:

Employee ID #

Employee Signature:

Date

Instructions to the Site Manager or DNR Division Representative

This section is for the Site Manager or DNR Division Representative only. As the employer of the above mentioned employee, you must complete one of the following documents located at the end of this hiring package. Place a check mark next to the document that you have completed. Keep the completed form with the new hire paperwork and forward it to the Office of Human Resources. An OHR representative will forward the document to the appropriate retirement system.

Rehired Retiree Reporting Form (ERS Retiree Only)

Rehired Retiree Reporting Form – LRS (LRS Retiree Only)

Public School Employees Retirement System Rehired Retiree Reporting Form (PSERS Retiree Only)

Employee Verification for a Retiree Returning to Work FT/PT/Temporary (TRS Retiree Only)

*G4$ALL*Rehired Retiree Reporting Form

O.C.G.A. § 47-2-110(b)(4) (ERS), O.C.G.A. § 47-23-109(c) (JRS), and O.C.G.A. § 47-6-84(d) (LRS)requires employers to notify the Employees' Retirement System of Georgia of any employees who have beenhired subsequent to retirement from the Employees' Retirement System, Judicial Retirement System, andLegislative Retirement System, respectively. If a rehired retiree exceeds the annual 1,040 hour worklimitation, the employer must reimburse ERSGA for any benefits wrongfully paid in the event the employerhas failed to notify ERSGA of the rehired employee’s status. It is the duty of the retired plan memberseeking employment to notify the employer of his or her retirement status prior to accepting employment.If a rehired retiree fails to notify the employer and the employer becomes liable to the retirement system,the plan member shall hold the employer harmless for all such liability.

In addition, O.C.G.A. § 47 -2-110 (a)(1)(B) (ERS) requires employers to certify to ERSGA that no agreement existed prior to retirement between the employer and the retiree to allow the retiree to return to service.

Employee Name_____________________________________________ ________________________ (Please Print) Social Security Number

Employer Reporting/Department #______________________

Employer Name_________________________________________________________________________

Date of Rehire____________________ Date

Employment Status (check one): Number of Hours expected to work annually:

Full Time Part Time ______________Hours

I hereby certify that no agreement to return to employment service existed between this department and this rehired retiree prior to the retirement date.

___________________________________________________ ____________________________ Signature – Department/Agency Official Date

Return this signed form to the Employees' Retirement System of Georgia within 30 days of hire. Mail to the following address:

Employees' Retirement System of Georgia Two Northside 75, Suite 300

Atlanta, GA 30318

G4ALL 11/2019 Page 1 of 1

___________________________________________________

462

Georgia Department of Natural Resources

REHIRED RETIREE REPORTING FORM - TRS

This form is to be completed by all employees who have previously retired from a position covered by the Teacher’s Retirement System of Georgia (TRS) and are currently receiving pension benefits from the TRS. The Department of Natural Resources is obligated to the TRS to verify the employment of TRS members. Do not complete this form if you are not a TRS retiree.

Last Name First Name Middle Name

Social Security # - - Contact Information

Home Phone

- - Mobile Phone

- - Email Address

Address

Home Street Address

Apartment #

City State Zip Code

County

Part-time

Hire Date

Job Title

Hourly Pay Rate

Full-time

Hire Date

Job Title

Annual Salary


☐ I am a retiree of the Teacher’s Retirement System of Georgia and am currently receiving pension benefits from the TRS. I am in compliance with O.C.G.A. 47-3-127.

Employee Name (print)

Employee Signature Date:

/ /