Employee Forms
Applying for an Internal Position
Questions? Call Michelle Kahl at extension 5024.
Please submit this form to the Human Resource Department to apply for a vacant position within your bargaining unit. You may also state your interest by sending an e-mail to mkahl@janesville.k12.wi.us.
Internal Applicant Form
Starting or Changing Tax Shelter Annuity
Questions? Call Lavonne Benash at extension 5051.
The district will help you save for your retirement with a retirement savings program. We will deduct an amount you specify from your paycheck and make automatic deposits to a pre-tax 403(b), after tax ROTH 403(b) or pre-tax 457 Deferred Compensation plan.
You can select from two venders to get started into a savings program. Contact either Retirement Plan Advisors (RPA) at 608-531-0190 or WEA at 800-279-4030 to receive information about their plans and the appropriate forms.
To change the deduction amount of an existing plan, please forward the Salary Reduction Agreement form to the Payroll Department.
To change the distribution of funds within your current plan, call either RPA or WEA at the above numbers.
Salary Reduction Agreement
Change your Choice of Payment for the following year
Changes to Choice of Payments must be submitted to the Human Resource Department. Please check forms for specific timelines. Changes can not be made during the school year. Questions? SCA Union members - Contact Michelle Kahl at x5024. JEA Union members - contact Deb Blazer at x5026.
JEA Choice of Payment Form
SCA Choice of Payment Form
Direct Deposit
Questions? Call Lavonne Benash at extension 5051.
We will direct deposit your paycheck to one financial institution of your choice. Please complete the Direct Deposit Authorization Form and forward to the Payroll Department. Don’t forget to attach a voided check!
Direct Deposit Authorization Form
Submitting Credits for Salary Schedule Placement
Questions? Call Deb Blazer at extension 5026.
In order to receive lane advancement from credits earned, a Course Information Form and a copy of your computerized grade report (official transcript for a Master’s Degree) must be submitted by the February 5th or September 1st deadlines.
Course Information Form
PDP Credit Request Form
Requesting a Chance of a Lifetime Leave
Questions? Call Angel Tullar at extension 5022.
After your supervisor has approved your request, the form below should be forwarded to the Human Resource Department for final approval. The form should be submitted by the 10th workday of the school semester in which you are requesting the leave.
Chance of a Lifetime Leave
Board Policy 4252 - Chance of a Lifetime Leave
Earned Release Time
Questions? Call Angel Tullar at extension 5022.
To use Earned Release Time, keep track of your hours on an Earned Release Time Sheet and submit to your supervisor. The dates that ERT can be used this year are located on the time sheet also.
Earned Release Time Committees
Earned Release Time Sheet
Change of Name/Address
Questions? Call Michelle Kahl at extension 5024.
Please complete this form if you have moved or changed your name and forward to the Human Resource Department. If you have moved due to marriage or divorce, please see the section labeled "Change in Marital Status".
Change of Name/Address Form
Change in Tax Withholding
Questions? Call Lavonne Benash at extension 5051.
If you need to change the amount of taxes withheld from your paycheck, please complete the following form and forward to the Payroll Department. Please complete only the Federal W-4 Form if you would like both state and federal withholding to be the same. If you would like Wisconsin withholding to be different, you should complete the Wisconsin Withholding form found below.
Federal W-4 Tax Withholding Form
Wisconsin Withholding Form
Change in Marital Status
Questions? Call Tonya Williams at extension 5021.
Please be sure to complete the following forms and submit to the Employee Benefits department within 30 days of your change in status. In addition to your district benefits, you probably would like to change the beneficiary for your state retirement account also. To do this, contact the Wisconsin State Retirement System at 1-877-533-5020.
Change of Name/Address Form
Health Enrollment Application
W-4 Withholding Form
Life Insurance Beneficiary Designation Form
Flexible Benefit Claim Submission
Questions? Call Angel Tullar at extension 5022.
If you are a member of our Flexible Benefit Plan with Diversified Benefit Services, please submit the following form with your receipts. If they receive your claim by the 5th of the month, they will write you a check on the 10th of the month. If they receive your claim by the 20th of the month, they will write you a check on the 25th of the month.
Flexible Benefit Plan Claim Form
Link to Diversified Benefits Website - www.dbsbenefits.com (our Customer Name: Janesville and Pin Number: J98V43L9)
Changes in Dependents on your Health Plan
Questions? Call Tonya Williams at extension 5021.
Please complete the attached form and send to Employee Benefits if you have added dependent children to your health plan through birth or adoption or if your children over the age of 19 are no longer attending college full-time. A new form is required each time you change dependents and needs to be submitted within 30 days of the change.
Health Enrollment Application Form
Changing your Life Insurance Beneficiary
Questions? Call Tonya Williams at extension 5021.
If you would like to change the beneficiaries to your life insurance, please print the following form and submit to Employee Benefits. You can also change the beneficiary to your retirement funds in the Wisconsin State Retirement System by calling 1-877-533-5020.
Health Insurance for Adult Children Up to Age 27 Dependent Verification Form
Effective January 1, 2010, Wisconsin Stat §632.885 requires health insurers to provide coverage for an adult child of the insured. The child must be:
• Over 17 but less than 27 years of age.
• Unmarried.
• Not eligible for coverage under a group health benefit plan that is offered by the child’s employer and for which the amount of the child’s premium contribution is no greater than the premium amount for his or her coverage as a dependent.
There may be a tax effect when health insurance coverage is provided to an adult child. An employee who enrolls a dependent who does not qualify as a dependent under the tax code will pay Wisconsin tax on the value of the insurance. Currently the amount of the taxable benefit is $600.88, which is our single COBRA rate.
If you wish to enroll an adult dependent child, forward the dependent verification form along with an updated UMR Health Enrollment Form to Tonya Williams in Employee Benefits. If you have any questions regarding the guidelines for the School District of Janesville’s dependent eligibility, please contact Tonya Williams at extension 5021 or twilliams@janesville.k12.wi.us.
Fortis Life Insurance Beneficiary Designation
Domestic Partner Affidavit
Please complete this form and return to the Human Resource Office if you are a member of the JEA and would like to register a domestic partnership with the District. If this form is on file in HR prior to the absence, JEA members may use family illness days for domestic partners. Domestic partners do not qualify for insurance coverage with the School District of Janesville.
Affidavit