Cell Phone Reimbursement Agreement - Excel

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Cell Phone Reimbursement Agreement - Excel Powered By Docstoc
					                                                           Electronic Communication Devices Service Stipend(s)
                        Employee ID                                 Record Number                                     Employee's Name (Last, First, Middle Initial)                                        Important
                                                                                                                                                                                                    Stipends issue from
                                                                                                                                                                                                   transactions entered
                                                                                                                                                                                                   into the Payroll System
                      Department Name                               Department Contact's Name              Department Contact's e-mail          Phone            Fax              Mail Stop        and distributes
                                                                                                                                                                                                   separately from all
                                                                                                                                                                                                   other pay.
This stipend is taxable income                                              Department Chartstring                                                         Enter Monthly Stipend Amount             Pay is disbursed
and will be reported on the
                                                                                                                                                             Medium ($51-
                                                                                                                                                                                                   from the same location
employee's W-2. This stipend                                                                                                                      Low                         High
                               SCO FUND                    DEPTID           CLASS           ACCOUNT          PROGRAM          PROJECT
                                                                                                                                                ($0-$50)         80)        ($81-150)
                                                                                                                                                                                         Specify   as Master payroll.
does not affect other
deductions such as retirement,
                                                                                                                                                                                                    Withholding amounts
unless provided for under
                                ED 9 0 0 0 0 -                        -                - 6 0 1 5 0 5 - X X X X X - X X X X X X -                                                                   are NOT subject to
collective bargaining unit

                                  MO.       YR.                                                                                          Employee's Signature
                                                                                                                                                                                                    Taxes are wiithheld
ACTIVATE STIPEND                                   Monthly stipend pay is approved on an annual basis
                                                                                                                                                                                                   on stipends at the rate
EFFECTIVE MONTH/YEAR                               and expires on June 30th of each Fiscal Year.
                                                                                                                                                                                                   of 25% FIT, 6% SIT.

                                                                                                          By signing this document I certify that I have reviewed the service request and           Stipends issue prior
                                  MO.       YR.    Deactivation request must be received by Payroll       approve activation of the requested communication device in accordance with the          to the 15th of the month
DEACTIVATE STIPEND                                 Services by the 15th of the effective month. Any       CSU Fresno Policy and Procedures for the Purchase and Use of Electronic                  following the date of
EFFECTIVE MONTH/YEAR                               issuance of unauthorized stipends will be subject to   Communication Devices. The service chosen is the most economical service plan            Stipend (e.g., July 2008
                                                   the normal collection process.                         that meets individual business needs.                                                    pay will issue by August
                                                                                                                                                                                                   15, 2008).
                                    Manager's Name                                                                               Manager's Signature

                                                                                                                                                                                                    Initial pay requests
                                                                                                                                                                                                   must be received by
                                                                                                                                                                                                   Payroll by 15th of the
                                                                                                                                                                                                   stipend month.
                  Requests for amounts greater than $150 must be supported by the plan and cost documentation, and requires approval by the division's Vice President.
                                 Vice President's Name                                                                        Vice President's Signature                                           Chartfield on this
                                                                                                                                                                                                   form will be used for
                                                                                                                                                                                                   the entire year for the

Transition Requirement if moving from a university owned cell phone/electronic device to a personal cell phone/electionic device.                                                                   Employee Elected to keep
Initial transition from a university issued cell phone to a stipend requires sign off from Procurement Services to acknowledge that the university cell phone service has been disconnected.       University Issued Cell Phone.
If this stipend request is due to this type of activity, send this form, along with a copy of the approved Employee Agreement for Stipends and Reimbursements of Electronic
                                                                                                                                                                                                         Yes              No
Devices/Services to Procurement Services. When the university cell phone service has been disconnected this stipend request will be forwarded to Payroll for processing.
                                                                                                                                                                                                    Employee Elected to keep
                      Name of Buyer in Procurement Services                                                                                                                                        University Issued Cell Phone
                                                                                                                                   Buyer's Signature
            Who Verified University Cell Phone Service was Disconneted                                                                                                                                        Number
                                                                                                                                                                                                         Yes              No
                                                                                                                                                                                                    Date University Cell Phone
                                                                                                                                                                                                      Service Disconneted.

Directions: Complete all the yellow (shaded) boxes in this form including signatures. The department shall retain the original approved documents. Mail a copy of this approved document along with a copy of
the approved Employee Agreement for Stipends and Reimbursement of Electronic Devices/Services form to Payroll Services, Mail Stop JA110. If handcarrying, go to Joyal Administration, Room 279. If you are
transitioning from a university owned cell phone to a personal cell phone with a stipend, please see section immediately above.

        71509612-1a66-4ee5-9365-5630d1f57f5a.xls                                                                                                                                                     Rev. 10/09/08

Description: Cell Phone Reimbursement Agreement document sample