ࡱ> ^a  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]`Root Entry Fu\ _WorkbookzSummaryInformation(DocumentSummaryInformation8h \pekwagner Ba= ThisWorkbook=U#8X@"1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Arial1Tahoma1Arial1Arial1Arial14Lucida Handwriting1Arial1 Arial1 Arial1$Arial1Arial1" Helvetica1 Arial1 Arial1Arial1Arial1Arial1Arial1 Arial1 Arial1 Arial1Arial1Calibri1 Calibri1Calibri14Calibri1 Calibri1Calibri1Calibri1,8Calibri18Calibri18Calibri1>Calibri14Calibri1<Calibri1?Calibri1h8Cambria1Calibri1 Calibri"$"#,##0_);\("$"#,##0\)!"$"#,##0_);[Red]\("$"#,##0\)""$"#,##0.00_);\("$"#,##0.00\)'""$"#,##0.00_);[Red]\("$"#,##0.00\)7*2_("$"* #,##0_);_("$"* \(#,##0\);_("$"* "-"_);_(@_).))_(* #,##0_);_(* \(#,##0\);_(* "-"_);_(@_)?,:_("$"* #,##0.00_);_("$"* \(#,##0.00\);_("$"* "-"??_);_(@_)6+1_(* #,##0.00_);_(* \(#,##0.00\);_(* "-"??_);_(@_) 000\-00\-0000 mm/dd/yy0.0 #,##0.0 0.0000 0.000 #,##0.000 0.00000 "$"#,##0.000 "$"#,##0.00 mmmm\-yy mmmm\-yyyy.00 mm\-yyyy00,'[<=9999999]###\-####;\(###\)\ ###\-####"Yes";"Yes";"No""True";"True";"False""On";"On";"Off"$[$-409]dddd\,\ mmmm\ dd\,\ yyyy mm/dd/yy;@ m/d/yy;@ m/d;@[$-409]mmm\-yy;@[$-409]h:mm:ss\ AM/PM 00000 yy/mm$"$"#,##0.000_);\("$"#,##0.000\) 0000                                                                  !   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U/2'Zqg";JH mSdNpۍ*ʪ*8YntwNC_"w_Vy,_f_?ЪnpZwkJ[C~9Qb]7>"BLN/ǜ@=BLN/ǜD <8xNAƿYDPRb bQ!z!D[EZ[a5@>[7&9ߴM'9͜9͟3;5*7Ɲh< T\ oK|g1 F~;FDg Unԣ/[?gEItNd!=y֚TSk}U W;}~1!KReg/SwkUhFFaPx?a$7$0eۘ,jV KGuzMQ6U}l8z;~X/+SLػ{Kꉋm%e4+ϖ3&~[covѥݼCym;yw.\hU`A4 ptQBF5R!GSy;2ۏ'Sr|F>'_/Wk boUr|OGSKꁕUsjCWtmoq'1}tx~L_]'7b?Iƻ Zywzg{17ȵ1Z 3  @@  hkdACCUMULATED LEAVE CERTIFICATIONEMPLOYE INFORMATION"Name (Last, First, Middle, Former)Social Security Number7Address (Street or P.O. Box No., City, State, Zip Code)Employment CategorySex Coverage Type Group No.SPOUSE/DEPENDENT INFORMATION"CERTIFICATION OF ACCUMULATED LEAVEc) Total Hours (a + b)h) Amount Certified (f x g)EMPLOYER INFORMATIONDate (Mo/Day/Yr)Signature of Agent Employer Name FOR EMPLOYE TRUST FUNDS USE ONLY"Department of Employee Trust Funds P.O. Box 7931Madison, WI 537072 TOTAL AMOUNT CERTIFIED (e + h))Is spouse employed by State of Wisconsin?Supplemental Sick Leave CreditsHealth Carrier NameCode1Years of Adjusted Continous Service0Hours of Matching Credits-General4Hours of Matching Credits-Protective ATRIUMDEAN HEALTH PLAN MERCYCARE,Termination Date or Date of Death (MM/DD/YY)Birthdate (MM/DD/YY)Position Title: "Reason for Termination (see above)FOR EMPLOYER USE ONLYBargaining Unit:, Years of service equal to or less than 24 Years of service greater than 244Premiums have been paid for coverage through (MM/YY)Effec. Date (MM/YY)Premium AmountCOMPCAREBLUE AURORA FAMILYCOMPCAREBLUE NORTHWESTCOMPCAREBLUE SOUTHEASTGHC - EAU CLAIREGHC - SOUTH CENTRALGUNDERSON LUTHERANHEALTH TRADITIONHUMANA EASTERNHUMANA WESTERNMEDICAL ASSOCIATES HMOPHYSICIANS PLUSPREVEA HEALTH PLANUNITY - COMMUNITYUNITY - UW HEALTH STANDARD PLANSTATE MAINTENANCE PLANCWis. Stat. 40.05 (4) (b) and Wis. Stat. 40.02 (25) (b) and (bc)3a) Enter unused sick leave hours (enter 0 if none),d) Highest Basic Pay Rate as State Employee.g) Highest Basic Pay Rate as State Employee *e) Amount Certified (c x d)* NOTE: In most cases the highest basic pay will be used, however there are some exceptions. Please refer to current bargaining agreements for represented employees. For some employees line g) will be calculated using the ending base pay rate, or, at the employee s request, the average of the employee s base pay rates during the three highest years. Contact the Office of State Employment Relations for clarification.;1. Is age 55 or over (age 50 if protective occupation); OR,2. Is applying for a disability benefit; OR 3. Died; OR5. Qualifies for delayed sick leave usage under 2003 WA 33 (Employee Terminating after 20 years but not eligible for immediate annuity)Q4. Qualifies for delayed sick leave usage under 1991 WA 39 (Public Official); ORvTHIS FORM MUST BE SUBMITTED WITHIN 30 DAYS AFTER TERMINATION. DO NOT SUBMIT BEFORE TERMINATION. TYPE OR PRINT IN INK.Health Plan Code Health Plan6Complete this form for each terminating employee who:.Does employe have health insurance coverage? =Submit to ETF at above address. Keep a copy for your records.:Enter an Y in the box if the extra 500 hours are included:Of) Enter Supplemental Sick Leave hours (include extra 500 hours if applicable)1Is employe dependent on spouse s STATE contract?x HEALTH PLAN NFORMATION (Complete Spouse s health carrier information if employe is dependent on spouse s state contract)Qb) Add other creditable leave hours (see instructions in Heath Insurance Manual)NETWORKUNITED HEALTHCARE NEWPS PATIENT CHOICE 1WPS PATIENT CHOICE 2WPS PREVEA HEALTH PLANHN42 is part of hidden formula; do not delete; will not print out on certContact Name and PhoneET-4306 (REV 03/2006)Seniority DateRetirement Date (Mo/Day/Yr)(Seniority Date at Retirement (Mo/Day/Yr)Years of Seniority From APPR Hourly Rate)9 Pay Unclassified Final Salary from APPR*12 Pay Unclassified Final Salary from APPRXXX-XX-!Classified Final Salary from APPR Livvia GoffjsR OSTUUVWchXY9^p |ab5jccc PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!ÄA theme/theme/theme1.xmlYOoE#F{oc'NjGuرhF[xw;23NjHH q Jĥ|@_73xM6{o~(fIyWk"޽aJCR$'Mnlu"^T$}*OIB.bQn̖kC 0>ACMȉ<&J &M5BNe tY>?#!mfKx=[Ԃu}ˆ ~umoLz^W/}ةLo;9iwk/_tV[,ac߬56YvYp1ϡAz 9ۮ7ެe ."Zk1~EȰ RӔ/x$( :7vʗsSj{"bF^x^xz?>~,ɸ7Gg_zy5^|?}V I򋧿>O~I|SQ>19D{<Ÿ8ߊaG@tOE*\ʻ/ yToN:"1Q(v; y4<$jbRa|PŻǴI Y3wJG݈8b2(<& QHT^w/B(`Z!94[Mc˴j`jG7;Q]o YC5*CocU 9 IQ/ RV+`%*;æWѼ9/#~7qZ$*cߓrUngN>%OOi Dh[BvoLJƌB6>p&>w O]>_x.eywQ,5,^<ؾt&9 ԔEЇIIqhJ#f6kAS&2D)p3ӕ5teO`jvzEOG)9cshger-# ~fu-ԙՍh&9܊- 6 AлY3hX"M$#Fz6#b.w*lyhĭɾ̮]nR3+=,)'Kak.zi X 8Ka6!_ 5[ M܆< kW Ds/Z/j@&8?&5- C⫲K3Zw1K|D!`~J0A?Uֶy&,Xg1K#[y$[BTV)bBRvVt=낕@[\׶Dž8d4~_@`rx \kp*O69mY&ԧ HE]HKN!Vj%2BƣJԊ=" u\ӵC&Y0>g4&oN)j rihr"VTU,koy#ŬjQJpRk3܎Ws;ɢ!JT~u "֠ۀW_ Nq֙4)ڬuZˋw֒TvќXHegvtm,{2Da*20V=CoOQ2'@C8D.IrG[Ȥiࠆ)d͛|?&f9>b|w##(ɇ"C *_p=ce΂aenv*Wm瓗{varAˇ$IDpKs6* ʢG0egAnlCYt֏$Ysă)2|FS` uz'Xr*󠍒F`Bi m/Ҷj9Xrmox86tFo˜ b`>ASDbƟPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!ÄA theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]   9xxd  dMbP?_*+%&(\?'q= ףp?(Q?)ףp= ?MAdobe PDFS o^XXLetterPRIV ''''0\KhCFF0EBDAStandard"^XX??&cU} j} E} mE}  E} E} mE} m E} E} mE} E} I E} E} } m!E} m w} $ w} mw} $ w} $ ~9v,xi@@ @ @ @  @Y@@@@{ " ############L "############ "############ &' %%%%%%%%k $; ############l Ellmmmmmmlll I AaxaaaaaH Bea aaaaaH Cna  aaaaac E h  aaaaaq D h F* yzzzzz  @@@@@@@@  AB   ! a     ! 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