Questar III Substitute Hiring Packet

FINGERPRINT CLEARANCE PROCESS/REQUIREMENTS
Q: How do I schedule a fingerprinting appointment?
A: Contact MorphoTrust by going to their website at www.identogo.com and clicking on New York
State on the map, or calling (877) 472-6915.
Q: MorphoTrust requires me to provide an “ORI Number.” What is an ORI Number and
what is it used for?
A: An ORI Number is a unique number that is assigned to the New York State agencies by the New
York State Division of Criminal Justice Services (“DCJS”). It is a way for both the vendor and DCJS
to know which agency to send the fingerprint results to once the fingerprinting process is complete.
Q: What is the ORI Number for the New York State Education Department (“NYSED”)?
A: The NYSED ORI Number/Code is:
TEACH
Q. What is the total fee for fingerprinting? The total fee for fingerprinting is $99.70.
A: The fee breakdown is $75.00
as follows: DCJS Fee
FBI Fee
14.75
MorphoTrust Fee
9.95
Total
$99.70
Q. What method of payment can I use for my fingerprint application fee?
A. The fingerprinting fee can be paid at the time of scheduling through a credit card or on-site at the
time of the fingerprinting appointment with a check or cash only. At this time, the fingerprint
scanning locations are not equipped to handle credit card payments. If you want to pay by credit card,
the fee must be paid online, or over the telephone in advance of your fingerprint scanning
appointment. The only way to pay for fingerprints at the time of scanning is by cash or checks (i.e.,
personal, business check, government check, certified check, bank check or money order made
payable to “MorphoTrust USA”)
Q: Where are the MorphoTrust locations in the state?
A: A list of currently available locations can be found at www.identogo.com. Select “NY” and then
click on “Locations” to view the listing.
Q: Are photos required to be submitted?
A: Yes. MorphoTrust takes a photograph at the time the fingerprints are scanned.
Q: What kind of ID information do I need to provide for fingerprinting?
A: You must have two forms of identification. At least one form of identification must contain a
photo.
EMPLOYMENT APPLICATION
PERSONAL INFORMATION
Name ____________________________________________________________________________________________
(FIRST)
(M.I.)
(LAST)
Present Mailing Address ___________________________________________________ Phone (
) _____________
_______________________________________________________________________ Zip ______________________
Email Address:
Are you currently a member of a New York State Retirement System?
If yes, what retirement system:  TRS  ERS
 Yes
 Other (please identify) _______________________________
Are you currently retired from any New York State Government employment?
If yes, what retirement system:  TRS  ERS
Are you legally eligible to work in the US?  Yes
 No
 Yes
 No
 Other (please identify) _______________________________
 No
Have you ever been fingerprinted for purposes of employment by New York State Education?  Yes
 No
Have you ever been convicted of a crime?  Yes  No If yes, please explain ______________________________
_________________________________________________________________________________________________
POSITION PREFERENCE
Position(s) applied for: _______________________________________________________________________________
How did you learn about the position(s) and/or Questar III? __________________________________________________
EDUCATIONAL PREPARATION
Name of location of school
Area of Studies
Degree
College(s)
High School
WORK EXPERIENCE
List most recent experiences first.
Dates Employed
Employer’s Name/Address/Phone
Name of Supervisor
1 of 4
Position
Reason for Leaving
REFERENCES
List three individuals having direct personal knowledge of your professional training, ability, experience and personal
character. Include the name, address and telephone number of your last supervisor who may be contacted for a reference.
Name
Position
Address/Telephone Number
I understand that Questar III may contact any and all of the employers I have listed on this application to verify the
information I have provided, as well as to obtain information about my present/prior work experience. I hereby
authorize the employers I have listed to speak candidly and openly with Questar III about my work experience with
them and thus release them from all liability in responding to inquiries in connection with my application.
I further understand that Questar III will verify the validity of appropriate certifications, licenses, and other pertinent
information related to the position(s) I have applied for.
I hereby certify that all statements made by me on this application are true and complete. I understand that any false or
misleading statements made by me will be considered a basis for disqualification of my application or termination of
employment.
Applicant’s Signature ____________________________________________________________ Date ____________
NON-DISCRIMINATION NOTICE FOR EMPLOYEES AND APPLICANTS FOR EMPLOYMENT
Questar III does not discriminate on the basis of race, color, national origin, sex, disability, age, religion, creed, sexual orientation,
military status, predisposing genetic characteristics, marital status, domestic violence victim status, or other characteristic protected by
federal or state law in its programs and activities, including but not limited to recruitment and appointment of employees, employee
pay and benefits, and other terms and conditions of employment. Questar III provides equal access to the Boy Scouts of America and
other designated youth groups. The following persons at Questar III have been designated to handle inquiries regarding Questar III’s
non-discrimination policies and the application of regulations prohibiting discrimination:
Title IX Compliance Officer
Questar III BOCES
10 Empire State Blvd.
Castleton, NY 12033
518-477-8771
504 Compliance Officer
Questar III BOCES
10 Empire State Blvd.
Castleton, NY 12033
518-477-8771
School Attorney
Questar III BOCES
10 Empire State Blvd.
Castleton, NY 12033
518-477-8771
For further information on notice of non-discrimination, or to inquire regarding the application of regulations prohibiting
discrimination, contact the U.S. Department of Education, Office for Civil Rights.
2 of 4
Special Education, Pre-K & Career Technical Education (CTE) Substitute Information
I am not interested in a substitute assignment for the 2016-17 school year. Please note your name below.
I am interested in a substitute assignment for the 2016-17 school year. Please complete all sections:
Position(s) preferred:
Teaching Assistant (TA)
Please Print
Last
Name
LPN
Teacher (not applicable in Special Ed)
First
Name
Middle
Initial
Address:
Phone:
(
Availability:
)
E-Mail:
Any day OR
Selected days:
Monday
Tuesday
Wednesday
Thursday
Friday
SPECIAL EDUCATION
Locations: Please check sites where you are willing to sub:
Columbia County:
Columbia Greene Ed Center (Hudson)
Ichabod Crane High School (Valatie)
Rensselaer County
Columbia High School (East Greenbush)
George Washington School (Averill Park)
Goff Middle School (East Greenbush)
Maple Hill Middle School (Schodack)
Red Mill Elementary (East Greenbush)
Rensselaer City MS/HS (Rensselaer)
Rensselaer Academy (Rensselaer)
Academy at Rensselaer Ed Center (Troy)
Sackett Educational Center (Castleton)
Sarah’s Sisters – Capital Region Arts Center (Troy)
Greene County:
Catskill Academy (Catskill)
PRE-K PROGRAMS
Locations: Please check sites where you are willing to sub:
Columbia County:
Ichabod Crane Primary School –Pre-K (Valatie)
John L. Edwards –Pre-K (Hudson)
Rensselaer County
Berlin Elementary- Pre-K (Berlin)
Greene County:
Cairo-Durham – Pre-K (Cairo Elementary)
Career Technical Education (CTE)
Locations: Please check sites where you are willing to sub:
Columbia County:
Columbia Greene Ed Center (Hudson)
Rensselaer County
Rensselaer Ed Center (Troy)
NON-DISCRIMINATION NOTICE FOR EMPLOYEES AND APPLICANTS FOR EMPLOYMENT
Questar III does not discriminate on the basis of race, color, national origin, sex, disability, age, religion, creed, sexual orientation, military status, predisposing genetic characteristics, marital
status, domestic violence victim status, or other characteristic protected by federal or state law in its programs and activities, including but not limited to recruitment and appointment of
employees, employee pay and benefits, and other terms and conditions of employment. Questar III provides equal access to the Boy Scouts of America and other designated youth groups. The
following persons at Questar III have been designated to handle inquiries regarding Questar III’s non-discrimination policies and the application of regulations prohibiting discrimination:
Title IX Compliance Officer
504 Compliance Officer
School Attorney
Questar III BOCES
Questar III BOCES
Questar III BOCES
10 Empire State Blvd.
10 Empire State Blvd.
10 Empire State Blvd.
Castleton, NY 12033
Castleton, NY 12033
Castleton, NY 12033
518-477-8771
518-477-8771
518-477-8771
jg-8-11
Return to Seth Stanton, Human Resources, Questar III - 10 Empire State Blvd., Castleton, NY 12033
New Employee Information
Name:
First
Last
M.I.
State
Zip
Address:
City
Home Phone:
Cell Phone:
Email:
Birth Date:
Marital Status:
Emergency Contact Information
Name:
Relationship:
Address:
Home Phone:
Cell Phone:
Paycheck Delivery (check one):
Mail:
* Selection only applies to 1st paycheck if
opting in to direct deposit
Pick-up:
Human Resource Office Use Only
Cobra Notice Needed:
Yes:
No:
* Check "Yes" if enrolling in to 2-person or
family insurance
Passport Information
Drivers License
Social Security Card or Birth Cert.
Form W-4 (2016)
Purpose. Complete Form W-4 so that your employer
can withhold the correct federal income tax from your
pay. Consider completing a new Form W-4 each year
and when your personal or financial situation changes.
Exemption from withholding. If you are exempt,
complete only lines 1, 2, 3, 4, and 7 and sign the form
to validate it. Your exemption for 2016 expires
February 15, 2017. See Pub. 505, Tax Withholding
and Estimated Tax.
Note: If another person can claim you as a dependent
on his or her tax return, you cannot claim exemption
from withholding if your income exceeds $1,050 and
includes more than $350 of unearned income (for
example, interest and dividends).
Exceptions. An employee may be able to claim
exemption from withholding even if the employee is a
dependent, if the employee:
• Is age 65 or older,
• Is blind, or
• Will claim adjustments to income; tax credits; or
itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages
greater than $1,000,000.
Basic instructions. If you are not exempt, complete
the Personal Allowances Worksheet below. The
worksheets on page 2 further adjust your
withholding allowances based on itemized
deductions, certain credits, adjustments to income,
or two-earners/multiple jobs situations.
Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
you claimed and may not be a flat amount or
percentage of wages.
Head of household. Generally, you can claim head
of household filing status on your tax return only if
you are unmarried and pay more than 50% of the
costs of keeping up a home for yourself and your
dependent(s) or other qualifying individuals. See
Pub. 501, Exemptions, Standard Deduction, and
Filing Information, for information.
Tax credits. You can take projected tax credits into account
in figuring your allowable number of withholding allowances.
Credits for child or dependent care expenses and the child
tax credit may be claimed using the Personal Allowances
Worksheet below. See Pub. 505 for information on
converting your other credits into withholding allowances.
Nonwage income. If you have a large amount of
nonwage income, such as interest or dividends,
consider making estimated tax payments using Form
1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
working spouse or more than one job, figure the
total number of allowances you are entitled to claim
on all jobs using worksheets from only one Form
W-4. Your withholding usually will be most accurate
when all allowances are claimed on the Form W-4
for the highest paying job and zero allowances are
claimed on the others. See Pub. 505 for details.
Nonresident alien. If you are a nonresident alien,
see Notice 1392, Supplemental Form W-4
Instructions for Nonresident Aliens, before
completing this form.
Check your withholding. After your Form W-4 takes
effect, use Pub. 505 to see how the amount you are
having withheld compares to your projected total tax
for 2016. See Pub. 505, especially if your earnings
exceed $130,000 (Single) or $180,000 (Married).
Future developments. Information about any future
developments affecting Form W-4 (such as legislation
enacted after we release it) will be posted at www.irs.gov/w4.
Personal Allowances Worksheet (Keep for your records.)
A
Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . .
A
• You are single and have only one job; or
Enter “1” if:
B
• You are married, have only one job, and your spouse does not work; or
. . .
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more
than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . .
C
Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . .
D
Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . .
E
Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit
. . .
F
(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you
have two to four eligible children or less “2” if you have five or more eligible children.
G
• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . .
▶
Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.)
H
{
B
C
D
E
F
G
H
For accuracy,
complete all
worksheets
that apply.
}
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
and Adjustments Worksheet on page 2.
• If you are single and have more than one job or are married and you and your spouse both work and the combined
earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2
to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form
W-4
Department of the Treasury
Internal Revenue Service
1
Employee's Withholding Allowance Certificate
OMB No. 1545-0074
▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
Your first name and middle initial
2
Last name
Home address (number and street or rural route)
3
Single
Married
2016
Your social security number
Married, but withhold at higher Single rate.
Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card. ▶
5
6
7
Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)
5
Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .
6 $
I claim exemption from withholding for 2016, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
8
Date ▶
▶
Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.)
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
9 Office code (optional)
Cat. No. 10220Q
10
Employer identification number (EIN)
Form W-4 (2016)
Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
IT-2104
New York State • New York City • Yonkers
First name and middle initial
Last name
Apartment number
Permanent home address (number and street or rural route)
City, village, or post office
State
ZIP code
Your social security number
Single or Head of household
Married
Married, but withhold at higher single rate
Note: If married but legally separated, mark an X in
the Single or Head of household box.
Are you a resident of New York City? ............Yes
No
Are you a resident of Yonkers?......................Yes
No
Complete the worksheet on page 3 before making any entries.
1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 17) ............ 1
2 Total number of allowances for New York City (from line 28) ................................................................................... 2
Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.
3 New York State amount ......................................................................................................................................... 3
4 New York City amount ........................................................................................................................................... 4
5 Yonkers amount ..................................................................................................................................................... 5
I certify that I am entitled to the number of withholding allowances claimed on this certificate.
Employee’s signature
Date
Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld
from your wages. You may also be subject to criminal penalties.
Employee: detach this page and give it to your employer; keep a copy for your records.
Employer: Keep this certificate with your records.
Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):
A Employee claimed more than 14 exemption allowances for NYS .............A
B Employee is a new hire or a rehire.... B
First date employee performed services for pay (mm-dd-yyyy) (see instr.):
Are dependent health insurance benefits available for this employee? .............. YesNo
If Yes, enter the date the employee qualifies (mm-dd-yyyy):
Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.) Employer identification number
Instructions
Changes effective for 2016
Form IT-2104 has been revised for tax year 2016. The worksheet on
page 3 and the charts beginning on page 4, used to compute withholding
allowances or to enter an additional dollar amount on line(s) 3, 4, or 5,
have been revised. If you previously filed a Form IT-2104 and used the
worksheet or charts, you should complete a new 2016 Form IT-2104 and
give it to your employer.
Who should file this form
This certificate, Form IT-2104, is completed by an employee and given
to the employer to instruct the employer how much New York State (and
New York City and Yonkers) tax to withhold from the employee’s pay. The
more allowances claimed, the lower the amount of tax withheld.
If you do not file Form IT-2104, your employer may use the same number
of allowances you claimed on federal Form W‑4. Due to differences in
tax law, this may result in the wrong amount of tax withheld for New York
State, New York City, and Yonkers. Complete Form IT-2104 each year
and file it with your employer if the number of allowances you may claim
is different from federal Form W-4 or has changed. Common reasons for
completing a new Form IT-2104 each year include the following:
• You started a new job.
• You are no longer a dependent.
• Your individual circumstances may have changed (for example, you
were married or have an additional child).
• You moved into or out of NYC or Yonkers.
• You itemize your deductions on your personal income tax return.
• You claim allowances for New York State credits.
• You owed tax or received a large refund when you filed your personal
income tax return for the past year.
• Your wages have increased and you expect to earn $106,950 or more
during the tax year.
• The total income of you and your spouse has increased to $106,950 or
more for the tax year.
• You have significantly more or less income from other sources or from
another job.
• You no longer qualify for exemption from withholding.
New York State Department of Labor
Division of Labor Standards
Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Pay Notice for Exempt Employees
Employer
Employee
Questar III
Company name: _______________________________________
Name: _______________________________________________
14-6013390
FEIN (optional): ______________________________________
Street address (include apartment): ________________________
10 Empire State Blvd
Street address: ________________________________________
_____________________________________________________
Castleton, NY
City and state: ________________________________________
_____________________________________________________
Zip code: ____________________________________________
City: ________________________________________________
NOT REQUIRED
518 ) __________ - _________________________
Phone: ( _______
State and zip code: _____________________________________
Seth Stanton
Preparer’s name: ______________________________________
Phone: ( _______ ) ________ - ___________________________
NOT REQUIRED
Human Resources Specialist
Preparer’s title: _______________________________________
$68/day Sub TA / $87.50/day Sub Teacher / $127.46/day Sub Nurse
Your rate of pay: ____________________________________________________________________________________________
Specify whether the rate of pay is on an hourly, salary, day rate, piece rate or other basis. If pay is for a specified number of hours, state the number
of hours.
n/a
You are exempt from a premium overtime pay rate under the _________________________________________________________
_______________________________________________________________________________________________ exemption.
Bi-weekly on Wednesday's
Designated pay day: __________________________________________________________________________________________
Date
Preparer’s signature
General Statement Regarding Overtime Pay in New York State
Most employees in New York State must be paid overtime wages of 1½ times their regular rate of pay for all hours worked over 40
hours in a workweek. A very limited number of specific categories of employees must be paid overtime at a lower rate or not at all.
I have been notified of my wage rate, overtime rate, and designated pay day on the date given below.
Date
Employee’s signature
The employee must receive a duplicate signed copy of this form. The original must be kept by the employer.
LS 59 (12/09)
* Optional Enrollment - only fill out if opting to enroll
QUEST,fRlll
DIRECT DEPOSIT AUTHORlZA TION FORM
PLEASE CHECK ONE:
D Change
D New Request
(complete previous bank and account information)
Previous Bank Name: _ _ _ _ __ _ __ _ __ _
Previous Account #:
EMPLOYEE INFORMATION:
Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Social Security # or Questar III Employee ID #: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
New Bank name: _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ __
o
Checking (Attach a voided check)
o Savings (Attach a deposit slip)
New Account number: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _
Emai l Add ress:
(For email invitation to MyWinCap Web in order to access Direct Deposit statements)
For direct deposit [0 savings account, please attach a copy of your voided deposit sl ip. For your
checking account, please attach a voided check. Without these, the direct deposit cannot be processed.
Please note that your name and address SHOULD be "imprinted" on deposit slip or cancelled check.
The above information will be va lid unti l new authorization is signed with the Payroll Office. If you
need to make changes to this authorization, you must fill out a new Additional Direct Deposit
Authorization Fonn. If you decide to cancel this authorization, a Stop Additional Direct Deposit Form
must be filled out. All forms must be returned to Questar III Payroll Office, 10 Empire State Boulevard,
Castleton, NY 12033.
I understand that this fonn authorized my net pay to be dispersed between two bankin g institutions as
indicated on my Direct Deposit Authorization and this Additional Direct Deposit Authorization. I also
understand that it is my responsibil ity to repon in writing [on proper fonn(s)] any and all changes to my
direct deposit{s) to the Payroll Office.
Signature
5 18.477.8771
Revised: 512010
10 Empire State Blvd., Castleton, New York 12033
www.guestar.org
Date
Fax: 5 18.477.9833
HR Fonns
* Benefit Acknowledgement Form - Optional Enrollment
403(b) Salary Reduction Agreement (SRA)
Employer Name
*Full time Employee
1. EMPLOYEE/PARTICIPANT INFORMATION
*First Name
*MI
*Social Security Number
*Part Time Employee
*Last Name
Date of Birth
*Date of Hire
*Address
Marital Status
*City
*Phone Number
*Union Member
*State
*Zip Code
*Email Address
2. AGREEMENT
The above named Employee elects to become a participant of the Employer’s 403(b) Plan and agrees to be bound by all the terms and conditions of the plan.
By executing this agreement, Employee authorizes Employer to reduce his/her compensation and have the amount contributed as an elective deferral and/or as
a salary reduction contribution to the Districts 403(b), Roth 403(b), or 457 Plan as permitted by the plan, on his/her behalf into the annuity or custodial accounts
as selected by the employee. It is intended that the requirements of all applicable State and or Federal income tax rules and regulations (Applicable Law) will be
met. Employee understands and agrees to the following:
1. This Salary Reduction Agreement is legally binding and irrevocable with respect to amounts paid or available while this agreement is in effect;
2. This Salary Reduction Agreement may be terminated at any time for amounts not yet paid or available, and that a termination request is permanent and
remains in effect until a new Salary Reduction Agreement is submitted; and
3. This Salary Reduction Agreement may be changed with respect to amounts not yet paid or available in accordance with Employer's administrative
procedures.
Questar III BOCES - Castleton, NY 12033
Employee is responsible for providing the necessary information at the time of initial enrollment and later if there are any changes in any information necessary
or advisable for Employer or Plan Administrator to administer the plan.
Employee is responsible for the following:
1. Employee is responsible for determining that the salary reduction amount does not exceed the limits set forth in applicable law determined by the IRS
Maximum Allowable Contribution (“MAC”) limits established for current plan year;
2. Providing accurate information when completing agreement;
3. Setting up and signing the legal documents required by law to establish an annuity contract or custodial account (including naming a death beneficiary), except in some cases when the Employer is required to establish the contract;
4. All distributions and any other transactions with Vendor. All rights under contracts or accounts are enforceable solely by Employee, employee beneficiary, or Employee’s authorized representative. Employee must contact Vendor directly and obtain Vendor’s paperwork when taking a loan, distribution, hardship distribution, initiating a transfer, or any other transaction. Employee is also required to have Plan Administrator sign and authorize all
paperwork from vendor when taking a loan, distribution, hardship distribution, initiating a transfer, or any other transaction, and may be required to
complete Plan Administrator forms in accordance with requested transaction.
5. Any and all losses suffered by Employee with regard to selection of the annuity and/or custodial account, which are both investment options that are
subject to gains and losses.
Employee agrees to indemnify and hold Employer and/or Plan Administrator harmless against any and all actions, claims, and demands whatsoever that may
arise from the purchase of annuities or custodial accounts. Employee acknowledges that Employer and/or Plan Administrator have made no representation to
Employee regarding the advisability, appropriateness, or tax consequences of the purchase of the annuity and/or custodial account described herein. Employee
agrees Employer and/or Plan Administrator shall have no liability whatsoever for any and all losses suffered by Employee with regard to his/her selection of the
annuity and/or custodial account. This agreement supersedes all prior Salary Reduction Agreements and shall automatically terminate if Employee’s employment is terminated.
*Please ensure you have contacted the service provider you selected & initiated an account under your school’s plan.
3. VOLUNTARY ELECTION & DEFERRAL INFORMATION (Election = Service Provider, Deferral = contribution)
Initiate New Election and Deferral
Service Provider Name
Change Election and/or Deferral
Account # (if known)
Old Contribution
Discontinue Election and Deferral
New Contribution
Effective Date
Standard Roth 457
4. NON-ELECTIVE CONTRIBUTION INFORMATION
*If your employer is making a one-time non-elective contribution as a retirement incentive or buyout of unused sick days please indicate the Service Provider you
have elected to send your funds to and provide the total amount of the contribution.
Service Provider
Account # (if known)
©Benetech, Inc. 2011 All Rights Reserved
Contribution Amount
Page 1 of 2
Effective date
Office Use Only
Date Submitted
Date Processed
5. PARTICIPATION OPT-OUT
I DO NOT WISH TO PARTICIPATE AT THIS TIME. I understand that I may participate in the future simply by filling
out a new Salary Reduction Agreement form.
6. SIGNATURES AND AUTHORIZATIONS
I certify that I have read this complete agreement and provided the information necessary for Employer to administer the Plan and that my salary reductions will
not exceed the elective deferral or contribution limits as determined by Applicable Law. I understand my responsibilities as an Employee under this Program, and I
request that Employer take the action specified in this agreement. I understand that all rights under the annuity or custodial account established by me under the
Program are enforceable solely by my beneficiary, my authorized representative or me.
*Employee Signature
*Date
To be Completed by Employer and Third Party Plan Administrator
*Employer Signature
*Date
*Print Name
*Title
*Third Party Administrator verifies this Salary Reduction
*Date
*Print Name
*Title
7. ACKNOWLEDGEMENT/APPOINTMENT OF FINANCIAL ADVISOR (IF APPLICABLE)
I agree to comply with all pertinent written directives regarding the solicitation of Employee. A calculation of maximum allowance
will be provided annually for Employee contributing more than $17,500 ($23,000 if over 50) or utilizing the “catch-up provisions”.
Furthermore, my employer (name)
agrees to indemnify and hold harmless the Employer, and individual
member of the governing board and the Employee participating in the 403(b) Program against any claims based on an error in the
MAC I provided, except where the error is based upon erroneous information provided by Employer or Employee. Additionally, I will
notify Benetech, Inc. regarding any distributions or loans to participants.
Advisor Name (Please print)
Phone
Address
City
Advisor Signature
Date
State
Zip Code
8. PREVIOUS EMPLOYER PLAN INFORMATION (REQUIRED FOR NEW HIRES)
Please complete this section if you have contributed to a previous employers 403(b) plan within the current calendar year.
*Name of Previous Employer
*Service Provider
*Year-to-Date Amount Contributed
Please return this completed form to Benetech, Inc. unless otherwise advised by your Employer:
Salary Reduction Agreements may also be completed online by visiting:
https://www.ebenefitsresource.com/boceweb/btlogin2.pgm
If you have any questions regarding this agreement please direct them to Benetech, Inc.
Benetech, Inc.
1 Dodge St. | P.O. Box 348
Wynantskill, NY 12198
Phone: (518) 283-8500 | Fax: (518) 880-4137
©Benetech, Inc. 2011 All Rights Reserved
Page 2 of 2
CERTIFIED EMPLOYEES
TEACHER &TEACHING ASSISTANTS
RETIREMENT OPTION FORM
TO:
FROM: Harry Hadjioannou, Assistant Superintendent for Business and Financial Services
DATE:
RE: Membership in Teacher’s Retirement System
Full-time teachers and full-time teaching assistants employed by Questar III must become members of the New
York State Teachers’ Retirement System. Employees working less than full-time for Questar III have the option of
joining or declining to join the New York State Teachers’ Retirement System. Should you decide to join, TRS
requires a 3.5% contribution regardless of salary prior to April 1, 2013; thereafter, the contribution rate in a given
school year is based upon regular compensation in the school year two years previously, as follows:





Wages of $45,000 or less...................3%
More than $45,000 to $55,000..........3.5%
More than $55,000 to $75,000..........4.5%
More than $75,000 to $100,000........5.75%
More than $100,000 to $179,000......6%
It should be clearly understood that part-time teachers and teaching assistants electing not to join the New York
State Teachers’ Retirement System will not be building any credits for retirement with them.
Please check your selection at the below. Be sure to sign, date and return it to the Payroll Office.
______ I wish to join the New York State Teachers’ Retirement System.
(Your check will be held until your application is received.)
______ I do not wish to join the New York State Teachers’ Retirement System.
(only applicable if less than 1.0 FTE)
______ I am already a member. My number is: NOT REQUIRED
______ I am a retiree. I retired on: ________________ My number is:
__________________
Date
NOT REQUIRED
______________________________________________________
Signature
______________________________________________________
Name (printed or typed)
518.477.8771
10 Empire State Blvd., Castleton, New York 12033
www.questar.org
Fax:518.479-6881
Revised: 5/2012
ORIENTATION CHECKLIST
QUESTAR III HUMAN RESOURCES DEPARTMENT
SUBSTITUTE’s

Welcome to Questar III. To assist you in becoming familiar with the organization, we have
developed the checklist below. We encourage you to ask questions as each item is discussed.
Upon completion of this checklist, sign and date below. Thank you for your time and
cooperation!
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
___
New Employee Info Sheet
I-9
W-4 Form (Federal Tax Form
IT-2104 (State Tax Form)
Labor Wage Statement
Direct Deposit
Tax Shelter Annuities (403-B)
Retirement Option Form/Application
Pension Cap Sign Off (If applicable)
Fingerprint Intake Form
Fingerprint 101 or 102 (Circle One)
Web site/Email Access/WinCap Web
Organizational Calendar/Days off Sheet
Timesheets
Pay Date Schedule
Questar Substitute Information
I acknowledge I have received all of the above:
Employee Name (Printed)
Signature of Employee
Payroll/HR Rep. Name (Printed)
Date
Signature of Payroll/HR Rep.
Date
NON-DISCRIMINATION NOTICE FOR EMPLOYEES AND APPLICANTS FOR EMPLOYMENT
Questar III does not discriminate on the basis of race, color, national origin, sex, disability, age, religion, creed, sexual orientation, military
status, predisposing genetic characteristics, marital status, domestic violence victim status, or other characteristic protected by federal or state
law in its programs and activities, including but not limited to recruitment and appointment of employees, employee pay and benefits, and other
terms and conditions of employment. Questar III provides equal access to the Boy Scouts of America and other designated youth groups. The
following persons at Questar III have been designated to handle inquiries regarding Questar III’s non-discrimination policies and the
application of regulations prohibiting discrimination:
Title IX Compliance Officer
Questar III BOCES
10 Empire State Blvd.
Castleton, NY 12033
518-477-8771
504 Compliance Officer
Questar III BOCES
10 Empire State Blvd.
Castleton, NY 12033
518-477-8771
School Attorney
Questar III BOCES
10 Empire State Blvd.
Castleton, NY 12033
518-477-8771
For further information on notice of non-discrimination, or to inquire regarding the application of regulations prohibiting discrimination,
contact the U.S. Department of Education, Office for Civil Rights.
Rev. 6/14