Electronic Communication Devices Service Stipend(s)
Employee ID Record Number Employee's Name (Last, First, Middle Initial) Important
Stipends issue from
into the Payroll System
Department Name Department Contact's Name Department Contact's e-mail Phone Fax Mail Stop and distributes
separately from all
This stipend is taxable income Department Chartstring Enter Monthly Stipend Amount Pay is disbursed
and will be reported on the
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,
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
Manager's Name Manager's Signature
Initial pay requests
must be received by
Payroll by 15th of the
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
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
Who Verified University Cell Phone Service was Disconneted Number
Date University Cell Phone
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