3399t New Employee Authorization Transmittal Form
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1Division of Administration and Business Services
District Fiscal Services
New Employee
Authorization Transmittal
Employee Information:
District Name: ______________________________
SELECT
Employee Name: _____________________________________
Employee Type: ___________
CE- Certificated
(Last)
(First)
(MI)
CL- Classified
Social Security Number (SSN): _________________________
NE- Student
Birthdate (mm/dd/yyyy): _________________________
BM- Board Member
Retirement Status:
Select the applicable status and complete information requested under the appropriate retirement system.
SELECT
SELECT
Employee is a ____________ member of ____________ .
District has:
verified* the employee’s PERS status in the myCalPERS Website.
□
verified* the employee’s STRS status in the CalSTRS Secured Employer Website (SEW).
□
*Verified by: _______________________ Phone: ________________
Date: ___________
(District Representative)
entered employee in Galaxy as a _________ member for the current position.
□
SELECT
Required Backup Information:
Copy of Employee’s Withholding Allowance Certificate (W-4)
□
Form is invalid if it has been altered.
Copy of Employee’s Withholding Allowance Certificate (DE-4)
□
If withholding allowance is different for the State.
□
Copy of Social Security Card
Copy needs to legible. If not legible – district must verify by writing the employee’s name and SSN next to the copy,
sign, and date.
Original PERS or STRS Election form (PERS: MAR or STRS: ES350 or ES372)
□
If applicable.
Copy of Employee's Driver License
Authorization:
Information indicated in this section will be verified with the district’s current Certification of Signatures form. Please note
that only original signatures from an authorized agent will be accepted.
Name: ___________________________________
Title: ________________________________
Authorized Signature: ________________________________
Date: ____________________
Submittal Information:
District is to keep original copies of all backup information in employee’s personnel file.
W-4/DE-4:
Tax Allowance Status: Married, Single, Head of Household must be indicated (unless filing exempt).
Withholding allowances must be indicated (unless filing exempt).
Additional withholding amount, if any.
Please note: W-4 or DE-4 with ten or more allowances, or exempt must be submitted to: W-4 Unit,
Franchise Tax Board MS F 180, P.O. Box 2952, Sacramento, California 95812-2952.
The employee’s name entered in Galaxy must match what is stated on the Social Security Card.
For forms previously submitted, please write “Previously Submitted” on the original form before resubmitting.
Form No. 3399T (Revised 05/13)
Distribution: Original- DFS, Copy- District
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