Prior State Service Verification Request Form

The University of Texas at Dallas

Office of Human Resources Management

Office: 972-883-2221

Fax: 972-883-2156

Prior Texas State Service Verification Request

To be completed by Employee: Please return to the Office of Human Resources Management mail station, AD10 (Copy form if needed).

Today’s Date: ____________________

SSN ___________________________________

Employee Name: _______________________________________

AKA: __________________________________

Texas State Agency/University

Dates of Employment

___________________________________________

______________________________________

___________________________________________

______________________________________

TRS Participation Date:__________ Have __Have Not__ Withdrawn Acct. Retired TRS/ERS/TX ORP: ___Yes ___No Ret. Date:____________

Signature: ________________________________________________________________________________________________

FOR UTD HRM USE ONLY:

FAX TRANSMITTAL

Date: __________________ To: ___________________________________________

Fax Number:____________________________

Requested By: _______________________________ E-mail: _____________________________

Phone: _________________________

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Only for UTD HR Review: LON elig? 24+ mo _____ FT _____ Longevity Memo done? _____ Rtn to work Retiree?____ Compl worksheet___

Rehired w/in one yr of separation? _____ Leave hours to Leave Admin? _____ Prev. ORP Elig_____ If yes, enter data on Lone Star______

To be completed by previous Texas State Agency or University:

Please verify prior service for the employee listed above and fax back to UTD at 972-883-2156. Attach separate sheet if needed.

Date(s) of Previous Employment: From:___________ To:___________ Position:____________________ FTE%:_____ Elig for Insurance? ____

From:___________ To:___________ Position:____________________ FTE%:_____ Elig for Insurance? ____

From:___________ To:___________ Position:____________________ FTE%:_____ Elig for Insurance? ____

Date paid through: _________________________________ (for purposes of direct transfer within state)

Did employee retire? ___Yes ___No If yes, what was retirement date? _________________ Employed in a student position? ___Yes ___No

If yes, what period:_______________________

Leave Information:

Transferable vacation hours: ____________ Transferrable sick leave hours: ____________ Balances through (date): __________________

Payroll Information: (To be reviewed and posted in HRIS)

Benefit Replacement Pay: $ _______________ Commission Date/Hazardous Duty Effective Date: _______________

Benefit Information:

Previously eligible for ORP: _____ No ____Yes

ORP Eligibility Date: ________________ ORP Enrollment Date: _________________

Vested: _____ Yes ______ No If Yes, Date Vested: _____________ UT Institutions Only: Met ACA eligibility?________ As of____________

Information Certified By:

Name: ________________________________________________

Title: __________________________________

Date: ____________

Signature: _____________________________________________________________________

Phone: ____________________________

Agency/Institution Name & No: ____________________________________________________________________________________________

Rev. April 2014