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Employee Request for final paycheck distribution

Please complete the form below. Required fields marked with an asterisk *

ROBSTOWN INDEPENDENT SCHOOL DISTRICT

EMPLOYEE REQUEST FOR FINAL PAYCHECK DISTRIBUTION

Name*

Answer Required

Social Security Number:

***-**-***

Answer Required

Phone Number:*

Home Phone or Mobile

Answer Required

Last Work Day:*

Answer Required

EMPLOYEE’S FINAL PAYCHECK SCHEDULED FOR:*

Answer Required

FOR RESIGNATION AND RETIREMENTS, THE EARLIEST YOU CAN REQUEST A PAY-OFF OF YOUR REMAINING CONTRACT BALANCE IS (please allow the district 5-7 working days advanced notice for processing request):

Answer Required

I elect to do the following with the remainder of my annual salary:*

Choose One Option:

Answer Required

A. Continue my paychecks as stated in Box 3 above.

B. Request a pay-off of my contract as stated in Box 4 above. (Employee must satisfactorily submit or account to the District for all reports, district property or equipment, and other items required by the District).

I understand that I will need to contact the Payroll Department regarding payroll deductions for the Texas Retirement System (TRS), federal income tax, other payroll deductions (health, dental, life, cancer, disability, vision, annuities, student loan payments, child support, membership dues to professional organizations and alternative teacher certification programs, etc.) as well as explaining insurance conversion and benefits continuation rights.

Electronic Signature:*

Answer Required

Date:*

Answer Required

Confirmation Email

Email Required