Prior State Service Verification Form
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1Prior State Service
Verification
The Prior State Service Verification form pertains to previous or current employment with a Texas State Agency. This form is
used to transfer your prior state service credit, leave balances, benefit replacement pay and/ or hazardous duty pay.
* Important: Disclosure of your Social Security Number (SSN) is requested from you in order for the University of Texas Health Science Center to verify
your pertinent prior state employment. No statute or other authority requires that you disclose your SSN for that purpose. Failure to provide your SSN,
however, may result in loss of your prior state employment information that affects pay, health and retirement benefits. Further disclosure of your SSN is
governed by the Public Information Act (Chapter 552 of the Texas Government Code.)
To be completed by Employee (Please Print):
_________________________________________________________
Prior State Agency or Institution:
__________________________________________________________________
Employee Name:
_____________________________
Are you a Direct Transfer?
Yes
No
SSN:
____________________________
Date of Hire (University of Texas Health Science Center at San Antonio) :
To be completed by the Prior State Agency or Institution (Please Print):
Dates of previous employment (enter dates in MM/DD/YYYY format):
: ____________
: ____________
: ____________
: ____________
From
To
From
To
: ____________
: ____________
: ____________
: ____________
From
To
From
To
Is this employee eligible for Hazardous Duty Pay?
Yes
No
If "Yes," Job Title: ___________________________
: ____________
: ____________
From
To
____________________
_______________
Sick Leave Balance:
Vacation Leave Balance:
____________________
Annual Benefit Replacement Pay:
Prepared by:
______________________________
_____________________________
Name :
Signature:
_____________________________
________________________________
Job Title:
E-mail:
________________________
______
__________
Phone Number:
State Agency ID:
Date:
UTHSCSA Department of Human Resources | hr-admin@uthscsa.edu | Fax 210.567.6791
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