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Tools and Forms

Last Modified: 2016-08-11

All forms are viewable using Adobe Acrobat (.pdf), unless otherwise noted.

Use the search box below to look for the form you need or use the column headers to sort the forms alphabetically or by form type.

Form Name Form Type
415(c) Aggregation Form Benefits
Leave Bank Adjustment Request - used to make increases/decreases to an individual's time off. Payroll
Adoption Reimbursement Request Form Benefits
Aetna HealthFund Health Option Benefits
Aetna Plus Health Option
Benefits

Aetna Select Health Option

Benefits
Aetna Claim Form (for domestic and international claims) Benefits
Benefit Appeal Request Benefits

Benefits Overview:

Benefits Overview 2016 for current employees (VUnetID required)

Benefits Overview 2016 for future employees (no VUnetID required)
Benefits
BlueCross BlueShield DentalBlue PPO - Claim Form Benefits
BlueCross BlueShield DentalBlue PPO Evidence of Coverage Benefits
BlueCross BlueShield DentalBlue PPO - Summary of Benefits Benefits
Cigna Dental Care (DHMO) Summary Plan Description Benefits
CIGNA Dental Care (DHMO) Summary Sheet (Patient Charge Schedule) Benefits
Attendance Tracker (2016) Employment
Criminal Background Disclosure Process Employment
Department Change Form Employment
Dependent Information Change Form Benefits

Direct Deposit Enrollment

Payroll
Employment Law Posters Employment
Enhanced Short-Term Disability Summary Plan Description Benefits
Exit Interview Questionnaire Employment
Family and Medical Leave Act (FMLA) FMLA
Family Status Change Request Benefits

Flexible Spending Account (FSA)

  • For claims, use Benefit Express . Log in with your VUnetID and ePassword and then look for the box "Flexible Spending Accounts" in the main column. Click here for a Benefit Express Reimbursement Claim Form.
Benefits
Health Care Plan Summary Plan Description Benefits
Label Request Form Payroll
Life and Accidental Death & Dismemberment Summary Plan Description Benefits
Long-Term Disability Certification of Prior Coverage Form Benefits
Long-Term Disability Summary Plan Description Benefits
Medicare Creditable Coverage Notice Benefits
MetLife Statement of Health Form Benefits
Navitus Compound Claim Form Benefits 
Navitus Drug Claim Form Benefits
Navitus Foreign Claim Form (for prescriptions purchased outside the United States) Benefits
Navitus Pharmacy Booklet Benefits
Notice of Privacy Practices Benefits
Notification of Family Status Change Benefits
Blank Payment Correction Request (Payroll Correction Request) - used for any event that includes the word prior (prior overtime, prior hours worked, prior increase to salary, etc.) Payroll
Retirement Plan Summary Plan Description Benefits
Superior Vision: Benefits Overview Brochure Benefits
Superior Vision Claim Form Benefits
Superior Vision: Finding In-Network Providers Benefits
Superior Vision: Summary Plan Description Benefits
Transferring a Vacant Position Quick Reference Guide Employment
Tuition Benefit for My Child Form Benefits

Tuition Benefit for Myself or My Spouse/Same-Sex Domestic Partner form
Note: The form has two pages and the Processing/Payroll Office must receive both pages before you begin your class. Please submit the form by the following dates, if possible. Fall Term: September 1; Winter/Spring Term (Winter: December 15. Spring: January 15); Summer Term: May 15.

How to Determine If Your Course Is Job-Related 

Request for Reimbursement for Tuition Expenses Form
Note: This form must be filed (along with your grade report and itemized invoice) after you have completed your class and before you begin your next class.

Benefits
Additional Pay Form: please use either the ePAC Additional Pay module or the Payroll Correction Request Employment
Employment Eligibility Verification (I-9)
  • /i9/  Instructions for completing I-9 Forms
Employment
Employee Information Forms: Employment
Paycard Application Form Employment
Performance Evaluation Employment
Performance Evaluation (Leadership Model) Employment
Personnel Action Form (New Hire PAF) Employment
Personnel Action Form - Distribution Form
Federal Centers
Employment
Personnel Action Form - Distribution Form
Non-Federal Centers
Employment
Personnel Action Form (Turnaround PAF)  
Position Description Questionnaire (PDQ) Employment
Position Description Questionnaire - EZ (PDQ-EZ) Employment
Position Management Form - see Transferring a Vacant Position Employment
End of Employment Process Checklist Employment
Reporting of Taxable Gifts, Awards, Prizes and Other “Perks” Employment
Summer Faculty Pay - see ePAC Employment
Stipend Request Form Employment
Traditional Short-Term Disability Summary Plan Description Benefits
How To Read Your W-2
W-2 Calculator
Employment
Federal Tax Forms:
W-4 Form for 2016

Form 1095-C information

State Tax Forms:

  1. Alabama A-4 Form (Alabama State Tax Withholding Allowance)
  2. Arizona A-4 Form (Arizona State Tax Withholding Allowance)
  3. California DE-4 Form (California State Tax Withholding Allowance)
  4. Colorado W-4
  5. Connecticut CT-W-4 (Connecticut Tax Withholding Allowance)
  6. Georgia G-4 Form (Georgia State Tax Withholding Allowance)
  7. Illionis IL-W4 (Illinois Tax Withholding Allowance)
  8. Indiana IN-WH4 (Indiana Employee's Withholding Exemption)
  9. Iowa IA-W4 (Iowa W-4)
  10. Kentucky K-4 Form (Kentucky State Tax Withholding Allowance)
  11. Kentucky K-4E form (Kentucky State Tax Withholding Allowance) For Exemption
  12. Louisiana L-4 (Louisiana Tax Withholding Allowance)
  13. Louisiana L-4E (Louisiana Exemption from Withholding Louisiana Income Tax)
  14. Maryland MW-507 Form (Maryland State Tax Withholding Allowance)
  15. Massachusetts M-4 (Massachusetts Tax Withholding Allowance)
  16. Minnesota W-4
  17. Mississippi Employee's Withholding Exemption Certificate
  18. Nebraska W-4
  19. New Jersey W4 Form (New Jersey State Tax Withholding Allowance)
  20. New Mexico W-4
  21. New York IT-2104 E (New York Non-withholding Form)
  22. New York IT-2104 (New York Tax Withholding Allowance)
  23. North Carolina NC-4 (North Carolina Tax Withholding Allowance)
  24. Ohio IT-4 Form (Ohio State Tax Withholding Allowance)
  25. Oklahoma W-4
  26. Oregon W-4
  27. Pennsylvania REV-419 AS (Pennsylvania Non-Withholding Form)
  28. Rhode Island W-4 (Rhode Island Tax Withholding Allowance)
  29. South Carolina W-4
  30. Utah W-4
  31. Vermont W-4
  32. Virginia-4 Form (Virginia State Tax Withholding Allowance)
  33. Washington D.C. D-4 Form (Washington D.C. Tax Withholding Allowance)
Employment
Non-FMLA Medical Leave FMLA
Alternative Work Arrangement Request Employment

Check Replacement Request Form 

Payroll
Commodore Award Eligibility and Criteria Other
Commodore Award Nomination Form Other
Electronic Communication Access Information Sheet Other

HR System Security Access Request Form

Human Resource System Security

Systems

Payroll Check Distribution Form 

Payroll

Waiver of No-Hire Provision

Employment

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