PLYMOUTH COMMUNITY SCHOOL CORPORATION · 2017-06-02 · sss s sssssssssssssssssss sssssssssss...

PLYMOUTH COMMUNITY SCHOOL CORPORATION

EMPLOYEE FORM FILL-IN

Date: ______________________

Employee Information

First Name: _______________________________ Last Name: _________________________________ M.I. _______

Date of Birth: ___________________ Social Security Number: _______________________Gender: Male Female

Address: __________________________________ City: _______________ State: _____________ Zip: ___________

Home Phone: _____________________ Cell Phone: ___________________ Marital Status: Single Married

Email Address: ____________________________________ Date of Hire: ____________________________________

Position: __________________________________________ Building: ______________________________________

Maiden Name: __________________________________________

Effective Date: __________________________________________

Office Use Only

Employee Number: __________________________________________

US Citizen?: Yes No

NEW EMPLOYEE ORIENTATION

FULL TIME CERTIFIED

COMPENSATION AND BENEFITS PAYROLL INFORMATION

Sick Bank

W4WH-4Verification of Eligibility


Pay Schedule Direct Deposit School Calendar Master Contract Sick Benefits Employee Assistance Program

INSURANCE PROGRAMInsurance Costs Health Insurance Portability MASE Booklet Life Booklet Disability Booklet Medical / Life / LTD Application Dental Booklet Dental Application

Vision Application Insurance Verification Insurance Benefits Letter Section 125 Form Cobra Notification

RETIREMENT INFORMATIONTRF Booklet TRF Application ISTA Welfare Benefits Plan & Trust MetLifeSecurity Benefit VEBA

GENERALJob Description Staff Discipline Guidelines Smoking Policy Drug Policy Workers Compensation TranscriptsExperience Record Employer Assisted Housing (EAH)Requisitions and Purchases Meal Reimbursement Teaching License Teacher Internship Application (Less than one year teacher) LifePlex Info/Enrollment Form

LEAVES, PROMOTIONS & TRANSFERS

Performance Evaluations TransfersHolidaysAbsences – Tardiness Jury Duty BereavementLeaves of Absence Maternity – Medical & Family Professional Leaves

Mileage Reimbursement Meal Reimbursement Other Reimbursement

ITEMS TO BE REC’D FROM EMPLOYEE

Experience Record TranscriptsExpanded Criminal History Check Teaching License Drug Policy

Job-Related Expenses Policy Anthem Summary of Benefits

P.T.M.A.F.

Vision Information

403b Information 403b Application

Highly Qualified Verification

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Disciplinary%20Actions.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Pay%20Schedule.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Employer%20Assisted%20Housing.pdf

http://eol.plymouth.k12.in.us/corporation/calendar.html

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Job%20Related%20Expenses-Administrative%20Guidelines.pdf

http://eol.plymouth.k12.in.us/corporation/staff/certified/Mastercontract.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/IRS%20Rule%20on%20Meal%20Reimbursement.pdf

http://eol.plymouth.k12.in.us/corporation/staff/certified/Mastercontract.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Bowen%20Center%20Employee%20Assistance%20Program.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/lnsurance%20Costs.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Health%20Insurance%20Portability%20and%20Accountability.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/MASE%20pamphlet.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Group%20Term%20Life%20Insurance.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Group%20Long%20Term%20Disability%20Insurance.pdf

holidayslink

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Summary%20of%20Dental%20Plan%20Benefits.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/VSP%20Information.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Policy%20FAMILY%20AND%20MEDICAL%20LEAVES%20OF%20ABSENCE.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/MASE%20Closed%20Enrollment%20Bulletin.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/cobra.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/403(b)%20UNIVERSAL%20AVAILABILITY%20NOTICE.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/adminguidelines%20Job%20Related%20Expenses.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Anthem%20Summary%20of%20Benefits.pdf

http://www.plymouth.k12.in.us/corporation/forms/orientation/TRFemployerHandbook.pdf

http://www.plymouth.k12.in.us/corporation/forms/orientation/ISTA%20Welfare%20Benefits%20Plan%20and%20Trust.pdf


PART TIME CERTIFIED Maternity Leave

COMPENSATION AND BENEFITS PAYROLL INFORMATION

W4WH-4

Verification of Eligibility


Pay Schedule Direct Deposit School Calendar Employee Assistance Program

RETIREMENT INFORMATION

GENERALJob Description Staff Discipline Guidelines Smoking Policy Drug Policy Substitute Teacher’s Handbook Letter of Reasonable Assurance


TranscriptsExpanded Criminal History Check Teaching License

Workers Compensation Criminal History Check

LifePlex Info/Enrollment Form Employer Assisted Housing (EAH)


Highly Qualified Verification



http://eol.plymouth.k12.in.us/corporation/apply/substitute/Handbook_for_substiture_teachers.pdf






PT to FT CLASSIFIED

COMPENSATION AND BENEFITS Time Sheet/Card (example)

PAYROLL INFORMATION

Direct Deposit

INSURANCE PROGRAMInsurance Costs Health Insurance Portability MASE Booklet Life Booklet Disability Booklet Medical / Life / LTD Application Dental Booklet Dental Application Vision Information

Insurance Verification Insurance Benefits Letter Section 125 Form Cobra Notification

RETIREMENT INFORMATIONPERF Booklet PERF Application

GENERAL


Job Description Staff Discipline Guidelines Smoking Policy Drug Policy Workers Compensation Criminal History Check

LifePlex Info/Enrollment Form Employer Assisted Housing (EAH)

Anthem Summary of Benefits

Vision Application


http://eol.plymouth.k12.in.us/corporation/forms/orientation/Blue%20Employee%20Time%20Sheet.pdf



http://eol.plymouth.k12.in.us/corporation/forms/orientation/lnsurance%20Costs%20CLASSIFIED.pdf










http://eol.in.gov/inprs/files/online_pe_handbook.pdf


NEW SUBSTITUTE EMPLOYEE ORIENTATION

PART TIME CLASSIFIED Employees working less than 20 hours/week.


PAYROLL INFORMATION



Pay Schedule Direct Deposit School Calendar Salary Policy

GENERALJob Description Staff Discipline Guidelines Letter of Reasonable Assurance Drug Policy Workers Compensation Employer Assisted Housing (EAH) LifePlex Info/Enrollment Form


Expanded Criminal History Check403b Information 403b Application








BUS DRIVER CLASSIFIED

COMPENSATION AND BENEFITSTime Sheet/Card (example)

PAYROLL INFORMATION

4W 4-HW



Pay Schedule Direct Deposit School Calendar Salary Policy Sick Benefits Employee Assistance Program


Insurance Verification Insurance Benefits Letter Section 125 Form Cobra Notification


GENERALJob Description Staff Discipline Guidelines Letter of Reasonable Assurance Uniforms, if applicable Smoking Policy Drug Policy Workers Compensation Employer Assisted Housing (EAH) LifePlex Info/Enrollment Form

LEAVES, PROMOTIONS & TRANSFERSPerformance Evaluations

srefsnarT syadiloH

Absences – Tardiness Jury Duty Bereavement Leaves of Absence Maternity – Medical & Family Professional Leaves


ITEMS TO BE REC’D FROM EMPLOYEEDOT Physical Expanded Criminal History Check

Job-Related Expenses Policy


Vision Application








holidayslink

http://eol.plymouth.k12.in.us/corporation/forms/orientation/lnsurance%20Costs%20BUS%20DRIVERS.pdf













http://eol.plymouth.k12.in.us/corporation/forms/orientation/TRFemployerHandbook.pdf


FULL TIME CLASSIFIED


PAYROLL INFORMATION

W4 4-HW





Insurance Verification Insurance Benefits Letter Section 125 Form Cobra Notification 403b Information

ITEMS TO BE REC


GJob D

ENERALescription

uidelines n

pensation ing )

ases


nt

amily

sement

’D FROM EMPLOYEE

Staff Discipline GLetter of Reasonable Assura ce Uniforms, if applicable Smoking Policy Drug Policy Workers ComEmployer Assisted Hous (EAH Meal Reimbursement Requisitions and PurchLifePlex Info/Enrollment Form

Performance Evaluations srefsnarT

Vacations syadiloH

Absences – Tardiness Jury Duty BereavemeLeaves of Absence Maternity – Medical & F Professional Leaves

Mileage Reimbur Meal Reimbursement Other Reimbursement

Expanded Criminal History Check

Job-Related Expenses Policy


Vision Application

403b Application





http://eol.plymouth.k12.in.us/corporation/forms/orientation/IRS%20Rule%20on%20Meal%20Reimbursement.pdf

http://eol.plymouth.k12.in.us/corporation/forms/orientation/Job%20Related%20Expenses-Administrative%20Guidelines.pdf



http://eol.plymouth.k12.in.us/corporation/forms/orientation/lnsurance%20Costs%20CLASSIFIED.pdf


holidayslink












http://eol.in.gov/inprs/files/online_pe_handbook.pdf


PART TIME CLASSIFIED Employees working less than 20 hours/week.

COMPENSATION AND BENEFITS

Time Sheet/Card (example)

PAYROLL INFORMATION




GENERAL Job Description Staff Discipline Guidelines Letter of Reasonable AssuranceUniforms, if applicable Smoking Policy Drug Policy Workers Compensation Employer Assisted Housing (EAH)LifePlex Info/Enrollment Form


Performance Evaluations TransfersVacations Absences – Tardiness Jury Duty BereavementLeaves of Absence Maternity – Medical & FamilyProfessional Leaves



Expanded Criminal History Check

Job-Related Expenses Policy 403b Information 403b Application


vacationslink









NEW EMPLOYEE AGREEMENT

This employee packet describes only the highlights of the school corporation policies, procedures, and benefits. In all instances the official benefit plan texts, trust agreements, and master contracts as appropriate are the governing documents. Your employee packet is not to be interpreted as a legal document or an employment contract. Employment with the School Corporation is at the sole discretion of the School Corporation and may be terminated for any reason. Nothing in this packet constitutes an express or implied contract or assurance of continued employment, or that just cause is required for termination. Understood and agreed: ______________________________________ (Employee’s Signature) ______________________________________ (Date)

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Form W-4 (2011) 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 2011 expires February 16, 2012. 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 $950 and includes more than $300 of unearned income (for example, interest and dividends).

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 may 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. 919, How Do I Adjust My Tax Withholding, 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. 919 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. 919 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. 919 to see how the amount you are having withheld compares to your projected total tax for 2011. See Pub. 919, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).

Personal Allowances Worksheet (Keep for your records.) A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You are single and have only one job; or • 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.

} . . . B

C 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

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E F Enter “1” if you have at least $1,900 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.) G 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 $61,000 ($90,000 if married), enter “2” for each eligible child; then less “1” if you have three or more eligible children. • If your total income will be between $61,000 and $84,000 ($90,000 and $119,000 if married), enter “1” for each eligible

child plus “1” additional if you have six or more eligible children . . . . . . . . . . . . . . . . . . G H 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

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 have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $40,000 ($10,000 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.

Cut 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

Employee's Withholding Allowance Certificate ▶ 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.

OMB No. 1545-0074

2011 1 Type or print your first name and middle initial. Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

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 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5 6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2011, 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 Date ▶(This form is not valid unless you sign it.) ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2011)

Form W-4 (2011) Page 2 Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2011 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . .

2 Enter: { $11,600 if married filing jointly or qualifying widow(er) $8,500 if head of household . . . . . . . . . . . $5,800 if single or married filing separately

} 3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 4 Enter an estimate of your 2011 adjustments to income and any additional standard deduction (see Pub. 919) 5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2011 Form W-4 Worksheet in Pub. 919.) . . . . . . . . . . .

6 Enter an estimate of your 2011 nonwage income (such as dividends or interest) . . . . . . . . 7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 8 Divide the amount on line 7 by $3,700 and enter the result here. Drop any fraction . . . . . . . 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . .

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet, also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

1

2

3 4

5 6 7 8 9

10

$

$

$ $

$ $ $

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.) Note. Use this worksheet only if the instructions under line H on page 1 direct you here. 1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . 4 5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5 6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6 7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $ 8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $ 9 Divide line 8 by the number of pay periods remaining in 2011. For example, divide by 26 if you are paid

every two weeks and you complete this form in December 2010. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . 9 $

Table 1 Table 2 Married Filing Jointly All Others Married Filing Jointly All Others

If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on paying job are— line 2 above paying job are— line 2 above paying job are— line 7 above paying job are— line 7 above

$0 - $5,000 0 $0 - $8,000 0 $0 - $65,000 $560 $0 - $35,000 $560 5,001 - 12,000 1 8,001 - 15,000 1 65,001 - 125,000 930 35,001 - 90,000 930

12,001 - 22,000 2 15,001 - 25,000 2 125,001 - 185,000 1,040 90,001 - 165,000 1,040 22,001 - 25,000 3 25,001 - 30,000 3 185,001 - 335,000 1,220 165,001 - 370,000 1,220 25,001 - 30,000 4 30,001 - 40,000 4 335,001 and over 1,300 370,001 and over 1,300 30,001 - 40,000 5 40,001 - 50,000 5 40,001 - 48,000 6 50,001 - 65,000 6 48,001 - 55,000 7 65,001 - 80,000 7 55,001 - 65,000 8 80,001 - 95,000 8 65,001 - 72,000 9 95,001 -120,000 9 72,001 - 85,000 10 120,001 and over 10 85,001 - 97,000 11 97,001 -110,000 12

110,001 -120,000 13 120,001 -135,000 14 135,001 and over 15

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to You are not required to provide the information requested on a form that is carry out the Internal Revenue laws of the United States. Internal Revenue Code sections subject to the Paperwork Reduction Act unless the form displays a valid OMB 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer control number. Books or records relating to a form or its instructions must be uses it to determine your federal income tax withholding. Failure to provide a properly retained as long as their contents may become material in the administration of completed form will result in your being treated as a single person who claims no withholding any Internal Revenue law. Generally, tax returns and return information are allowances; providing fraudulent information may subject you to penalties. Routine uses of this confidential, as required by Code section 6103. information include giving it to the Department of Justice for civil and criminal litigation, to The average time and expenses required to complete and file this form will varycities, states, the District of Columbia, and U.S. commonwealths and possessions for use in depending on individual circumstances. For estimated averages, see theadministering their tax laws; and to the Department of Health and Human Services for use in instructions for your income tax return.the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to If you have suggestions for making this form simpler, we would be happy to hear federal law enforcement and intelligence agencies to combat terrorism. from you. See the instructions for your income tax return.

Full Name Social Security Number

Home Address City State Zip Code

Indiana County of Residence as of January 1: (See instructions)

Indiana County of Principal Employment as of January 1: (See instructions)

How to Claim Your Withholding Exemptions1. Each taxpayer is entitled to one exemption. If you wish to claim the exemption, enter "1"............................................

2. If you are married and your spouse does not claim his/her exemption, you may claim it, enter "1".............................

3. You are allowed one (1) exemption for each dependent. Enter number claimed . Additional exemptions areallowed if: (a) you and/or your spouse are over the age of 65 and/or (b) if you and/or your spouse are legally blind.Check box(es) for additional exemptions: You are 65 or older or blind Spouse is 65 or older or blindNumber of boxes checked . (See instructions) Enter the total number of exemptions...................................................

State of IndianaEmployee's Withholding Exemption and County Status Certificate

Form WH-4SF 48845Revised 7-99

!!! !

!!

This form is for the employer's records. Do not send this form to the Department of Revenue.The completed form should be returned to your employer.

▲▲

$

4. Add lines 1, 2, and 3. Enter the total here..................................................................................................................................................

5. You are entitled to claim an additional exemption for each qualifying dependent (see instructions)......................

6. Enter the amount of additional state withholding (if any) you want withheld each pay period....................................... I hereby declare that to the best of my knowledge the above statements are true.

Signature Date:

Instructions for Completing Form WH-4This form should be completed by all resident and nonresident employees having income subject to Indiana state and/or county income tax.

Print or type your full name, social security number and home address on the appropriate lines of the Form WH-4. Enter your Indiana county of residence and county of principalemployment as of January 1 of the current year. If you did not live or work in Indiana on January 1 of the current year, enter "not applicable" on the line(s) . Your county taxwithholding is based first on the county where you lived on January 1. If that county has adopted a county income tax, then you are subject to that county's resident tax rate on yourearnings for the rest of the year or until you are no longer an Indiana resident. If the county in which you lived has not adopted a county income tax, then you are subject to thenonresident tax rate of the county in which you were employed on January 1 of the current tax year. If you move to (or work in) another county after January 1, your county statuswill not change until the next calendar tax year.

Lines 1 & 2 - You are allowed to claim one exemption for yourself and one for your spouse (if he/she does not claim the exemption for him/herself). If a parent or legal guardianclaims you on their federal tax return, you may still claim an exemption for yourself for Indiana purposes. You cannot claim more than the correct number of exemptions;however, you are permitted to claim a lesser number of exemptions if you wish additional withholding to be deducted.

Line 3 - Dependent Exemptions: You are allowed one exemption for each of your dependents based on state and federal guidelines. To qualify as your dependent, a person mustreceive more than one-half of his/her support from you for the tax year and must have less than $1,000 gross income during the tax year (unless the person is your child and isunder age 19 or under age 24 and a full-time student at least during 5 months of the tax year at a qualified educational institution). Additional Exemptions: You are also allowedone exemption each for you and/or your spouse if either is 65 or older and/or blind up to a maximum of four (4) additional exemptions. Enter the total number of dependents andadditional exemptions claimed on the line provided.

Line 4 - Add the total of exemptions claimed on lines 1, 2, and 3. Enter the total in the box provided.

Line 5 - Additional Dependent Exemption: An additional exemption is allowed for certain dependent children that are included on line 3. The dependent child must be a son,stepson, daughter, stepdaughter and/or foster child. Enter the total in the box provided.

Line 6 - If you would like an additional amount to be withheld from your wages each pay period, enter the amount on the line provided. NOTE: An entry on this line does notobligate your employer to withhold the amount. You are still liable for any additional taxes due at the end of the tax year. If the employer does withhold the additional amount,it should be submitted along with the regular state and county tax withholding.

You may file a new Form WH-4 at any time if the number of exemptions increases. You must file a new Form WH-4 within 10 days if the number of exemptions previouslyclaimed by you decreases for any of the following reasons:(a) you divorce (or are legally separated from) your spouse for whom you have been claiming an exemption or your spouse claims him/herself on a separate Form WH-4;(b) someone else takes over the support of a dependent you claim or you no longer provide more than one-half of the person's support for the tax year; or(c) the person who you claim as an exemption will receive more than $1,000 of income during the tax year.

Penalties are imposed for willingly supplying false information or information which would reduce the withholding exemption.

_____________________________ __________________

`|_______________________________||||||||||||||||||||||||||||||||||| |||||| ||||Direct Deposit Authorization Form ________________________||||||||||||||||||||||||||||||||||||______||_

Direct Deposit is Mandatory.

This form must be filled out before

you can receive your fist pay.

Name _______________________________________

Employee Number (if applicable) _________________ Address

Telephone Number _____________________________

Social Security Number _________________________

I hereby authorize Plymouth Community School Corp. company name

to deposit my pay automatically to the account listed below. Adjusting entries to correct errors are also

authorized. This authority will remain in effect until I have cancelled it in writing.

Institution ____________________________________

Transit/ABA routing # __________________________

Account # _______________________

Deposit to (choose one) Savings ____ Checking ____

PLEASE ATTACH A DEPOSIT SLIP OR VOIDED CHECK TO THIS AUTHORIZATION.

Signature Date

There have been recent changes to the payment system rules for direct deposit of payroll. If you receive your payroll via direct deposit at a U.S. bank and then have the entire payroll amount forwarded to a bank in another country, please advise the payroll department (or specific individual within your company). There are new formatting requirements for these transactions that the company needs to follow. It will not impact your payroll.

________________________________

________________________________

Name: _____________________________

SICK BANK FORM

I would be willing to donate a sick day to the Corporation sick bank. Please deduct

______ days from my sick leave balance.

Signature

I would not be willing to donate a sick day.

Signature

Date: __________________________________

CONSTITUTION, 2000

PLYMOUTH TEACHERS MUTUAL ASSISTANCE FUND

P.T.M.A.F.

Article I. Purpose

The Plymouth Teachers Mutual Assistance Fund (PTMAF) is organized for the purpose of cushioning the increased costs often associated with long term illness by providing mutual assistance to each other when time and/or salary are lost because of illness. PTMAF is not medical insurance but an assistance fund for all other increased expenses that may occur.

Article II. Membership

All individuals employed as certified teachers or administrative officers of Plymouth Community Schools are eligible for voluntary membership. Half-time teachers shall pay one-half the assessment and receive one-half the benefit.

Application of new participants must be completed within 30 school days following opening in the fall.

Article III. Assessments

The assessment shall be payable within 60 days following the opening of school in the fall. A teacher is not considered an enrolled member of PTMAF until scheduled fees are paid.

The assessment rate shall be $70 per member. After that time, a member will be considered paid-up provided that the member is still employed by the Plymouth Community Schools. No refund shall be made in case of termination, resignation, or retirement. However, if the fund should fall below $3500.00, the PTMAF board shall then assess all members the yearly dues of $10.00 until the fund exceeds $3500.00. There shall be no more than one assessment per school year.

Article IV. Administration

The funds of the PTMAF shall be under the management of a board composed of eight teachers selected as follows: one from Washington, one from Menominee, one from Webster, one from Jefferson, two from Lincoln, and two from Plymouth High School. The Superintendent of Schools shall be an ex-officio member of the board. The Treasurer may or may not be included in this board of eight. Each students represented will choose and replace any retiring members.

Officers shall be President, Vice-president, Secretary, and Treasurer. The Treasurer shall be bonded. At the beginning of each school year, the PTMAF board shall meet and organize.

It shall be the duty of the PTMAF board to:

1. Determine all forms and procedures for administration of the fund. 2. Receive application for benefits submitted by members. 3. Determine the eligibility and considerations of benefits to be paid. 4. Direct payments of benefits to entitled members.

The Board has the power to make the final interpretations of any phrase of clause in this Constitution.

Article V. Benefits:

1. The rate of benefits per school day to members of the PTMAF shall be $100.000. Benefits will begin when 30 eligible days of sick leave have been recorded as used in the current school year, in the records of Plymouth Community Schools, and will continue for a maximum of 35 additional school days eligible for sick leave. The total amount any member may collect is $3500.00 per school year, with a maximum of $7000.00 per lifetime benefits.

2. The PTMAF shall pay each teacher for eligible absences per the current master contract of illness of the teacher, spouse, or children living in the household. The PTMAF shall not be used for maternity unless said maternity results in a medical condition accompanied by a physician’s certificate, which specifically prohibits the person from returning to work due to medical reasons.

3. The benefits shall be paid in a timely manner, which could be considered a payment of once every two weeks.

4. The PTMAF can make no payment of benefits that will cause the balance to fall below zero. In the event there is not sufficient funds in the treasury to pay $100.00 per day, funds will have to be paid on a retroactive basis, as new funds become available.

Article VI. Surplus

The balance at the end of the year, if any, shall be carried over as surplus

Article VII. Death

In case of the death of a PTMAF member, the board has the power to determine the facts and make allowance for payment of days of absence for which there can be no claim filed.

Article VIII. Amendments

The constitution can be amended by a two-thirds vote of all members of the PTMAF.

Plymouth Teachers Mutual Assistance Fund

Membership Form

I, ________________________________________, wish to become a member of the Plymouth Teachers Mutual Assistance Fund (PTMAF). I understand that this form must be completed and submitted within 30 school days following the opening of school in the fall. I also realize that the assessment rate of $70.00 is to be paid within 60 days following the opening of school.

Once I have joined, I will not be charged any other dues unless the fund should fall below $3,000.00 at which time I cannot be charged more than $10.00 per year.

Once I am a member, I continue as such as long as I am still employed by Plymouth Community Schools.

______________________________ (Signature)

______________________________ (Date)

M A New Enrollment Annual Plan Election

MIDWEST AREA SCHOOL EMPLOYEES' INSURANCE TRUST ChangeS E

multiple employer welfare arrangement may not be subject to all of the insurance laws and regulations ofIndiana. State insurance guaranty funds are not available for your multiple employer welfare arrangement.

The Midwest Area School Employees' Insurance Trust is a multiple employer welfare arrangement. The

PLEASE PRINT

EMPLOYER INFORMATION

School Corporation: Plymouth Community School Corporation No. of Hours to be Worked Per Week_________________

Date of Hire_______________________________________________________ Position_________________________________________

EMPLOYEE INFORMATION Last Name First Middle Date of Birth Social Security Number

Home Address Male Single Widowed Divorced Female Married Separated

Home Phone

City State Zip Code

Yes No Effective Date: Amount of Coverage___ 50,000.00NIS LIFE GROUP #16577 - 7469

Name of Primary Beneficiary Relationship

Date of Birth Social Security Number

Name of Secondary Beneficiary - OPTIONAL Relationship


Yes No Effective Date:__________ Monthly Earnings $________________LTD NIS - MNL Group 16577 7228

Name of Beneficiary (IF DIFFERENT THAN ABOVE) Relationship


ACCEPTANCE

with respect to any of my dependents covered under the Trust. I agree to cooperate fully with the Trust and shall provide any information requested by the Trust within five (5) days of the request.

insurance.

DateSignature of patient/employee

and belief, and understand that the said answers and statements form the basis upon which insurance will be made effective. I understand that omissions, misrepresentations, or misstatements could result in denial of an otherwise valid claim and voiding or reparations of

2. I hereby certify that the dependents listed are my dependents as defined in the benefit plan. I agree to notify my employer of any change in status of any dependent, or of any additional dependents I may acquire.

4. I hereby represent and agree that all the answers and statements on this request are full, complete and true, to the best of my knowledge

receive any recovery, by way of judgment, settlement or otherwise, from another person or business entity, I will reimburse the Trust in full, in first priortiy, for any covered expenses paid by it. I understand and agree that this right of subrogation and/or reimbursement shall also apply

3. As a condition to receiving benefits under the Trust, I agree to transfer to the Trust my right to make claim, sue and recover from any person or business entity any funds paid or payable as a result of personal injury or reimbursement for covered expenses. Alternatively, if I

1. I hereby request the amount(s) and form(s) of coverage for which I am eligible under the plans of my employer and I authorize same todeduct the required contribution from my earnings. I understand that I have the right to revoke this deduction authorization by written request, subject to Section 125 rules, if applicable. I hereby knowingly and freely waive my eligibility for types of coverage checked in the REFUSAL section.

REFUSAL OF COVERAGE I would like to waive coverage under the Trust. You must sign the below.

If you are declining coverage, are you covered under another health plan? Yes No

If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this plan, provided that you request enrollment within thirty days after your other coverage ends. In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents, provided that you request enrollment within thirty days after the marriage, birth, adoption, or placement for adoption.

I have decided not to apply for coverage for: MEDICAL Self LIFE LTD Dependent

SIGNATURE ____________________________________________________________ DATE________________________________

SIGNATURE OF AUTHORIZED PERSONNEL ___________________________________ DATE________________________________

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Enrollment Application Anthem provides administrative claims payment services only, and does not assume any financial risk or obligation with respect to claims.

Please complete in ink and return to your employer. Use extra sheets of paper if necessary. All information given should apply to this employer. Anthem’s Primary Care Physician (PCP) listings, for HMO/POS products can be obtained through www.anthem.com.

2

/ /

/ / / / / / Yes No / /

1. Employer Use: Employer Name and Address:

Group # Sub-group # Request. Effective Date Applicant #/Dept. name

Pre-ex (date)COBPCPVision Effective DateDental Effective DateHealth Effective DateAnthem use: Plan

2. Reason for Application

New enrollment Waiver Annual open enrollment COBRA Conversion Qualifying event Event date ___/___/___

New hire Rehire (date) / / Add dependent (see section 3)

Event date / /

Marriage Birth

*Include legal documentation.

Adoption* Legal guardianship* Other

Last name First name, M.I. Date of birth

/ /

Home address City

Home telephone Business telephone

4. Type of Coverage/Plan

Health Coverage Dental Coverage Vision Coverage

HMO* (not applicable to Ohio)

Blue Traditional®

POS PPO EPO (Ohio only) Lumenos

� Health Savings Account

Lumenos �

Health Reimbursement Account Lumenos

� Health Incentive Account

Employee only Employee + spouse Employee + child(ren) Family coverage No coverage

Yes No

PPO Traditional (Indiana and Ohio only)


Vision


Age Sex

M F

Social Security # (SS# required for Lumenos

� Health Savings Account)

- -

State Zip code

eMail Address

Full time hire date Hours working per week

Anthem PCP ID number*

County (KY residents include Municipality)

/ /

Single Divorced Married

Income reported by: W2 Other:

1099

New patient?* Yes No

( ) - ( ) -

Are you:

Retired? Disabled? Hospitalized? Yes

No

Yes

No

Yes

No

Anthem PCP name and address*

3. Status Change/Event

5. Employee Information *Only complete Primary Care Physician (PCP) information if enrolling in HMO or POS products.

6. Family Information Spouse and dependents to be enrolled. (Attach a separate sheet if necessary.) *Only complete Primary Care Physician (PCP) information if enrolling in HMO or POS products.

Occupation

1 Last name First name, M.I.

Is dependent’s address different than applicant’s address? NoYes

Fulltime student?

Yes No

Son Other

Relationship to applicant

Spouse Daughter

Yes

Yes

Yes

No

No (If yes, include legal documentation)

No (If yes, give reason)

(If Yes, provide full address)

Eligible for federal income tax exemption?

Court ordered health care benefits?

Currently hospitalized or disabled?

Anthem PCP ID number*


Spouse Daughter

New patient?* Yes No

Son Other

Fulltime student?

Yes No

Date of birth

/ /

Sex

M F

Social Security #

- -

Anthem PCP name and address*

3 Last name First name, M.I.

Is dependent’s address different than applicant’s address? NoYes (If Yes, provide full address)

Yes

Yes

Yes

No






Date of birth

/ /

Sex

M F

Social Security #

- -

Yes

Yes

Yes

No






Date of birth

/ /

Sex

M F

Social Security #

- -

Anthem PCP name and address* Anthem PCP ID number* New patient?*

Yes No

2 Last name First name, M.I. Relationship to applicant

Spouse Daughter

Son Other

Fulltime student?

Yes No

Is dependent’s address different than applicant’s address? Yes No (If Yes, provide full address)


NoYes

A-77 8/06 LG-ASO


Spouse Daughter

Son Other

Fulltime student?4 Last name First name, M.I.

Yes

Yes

Yes

No






Date of birth

/ /

Sex

M F

Social Security #

- -

Yes No

Is dependent’s address different than applicant’s address? Yes No (If Yes, provide full address)


NoYes

Anthem will facilitate the opening of a Health Savings Account in your name, if directed by your Employer.

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7. Other Health Coverage Please check one: YES (completed below.) NO

On the day your coverage begins, list family members, including yourself, who will be covered by any other health coverage.

Provide name, phone number and address of the HMO or insurance company

Policy/certificate holder’s name

If you and/or your dependents are enrolled in Medicare or Medicaid, complete the following.

Social Security number

Effective datePolicy/certificate number

Date of birth

Enrollee’s name(s) Medicare / Medicaid ID# Medicare Part A Medicare Part B ESRD onset date effective date effective date

Medicare Part D ID# Medicare Part D Carrier Medicare Part D Medicare Part D effective date term date

Reason for Medicare entitlement:


Have you been covered by Anthem within the past two (2) years? Yes No

Age Disability ESRD & Disability End Stage Renal Disease (ESRD)

8. Prior Health Coverage Please check one: YES (completed below.) NO

Policy/Certificate #:

Have you and / or your dependents had prior coverage with another carrier(s)

within the past two (2) years? Yes No

Dates policy in effect:

Dates policy in effect:

Please check the type of prior coverage

Termination reason:

Employee Employee / Spouse

Divorce/legal separation Death of spouse

Employee / Child(ren)

COBRA coverage exhausted

Employee / Spouse / Child(ren)

Employment terminated Group plan terminated Employer/group contribution ceased

Other:

Significant Terms, Conditions and Authorizations (TERMS)

Please read this section carefully before signing the application.

1. I may not assign any payment under my Anthem Blue Cross and

Blue Shield administered benefit plan.

2. I authorize deduction from my wages/pension, if necessary for the required payment for

the benefit for which I, or any dependents have applied.

3. I am applying for the benefit selected on this application. If I select a coverage, or

combination of coverages, not available to me and / or a class for which I am not

eligible, I agree that my selection(s) is hereby automatically amended to be consistent

with the employer’s application.

4. I understand that, to the extent permitted by law, Anthem reserves the right to accept or

decline this application and that no right whatsoever is created by this application. I also

understand that this coverage, if approved, may exclude coverage for pre-existing

conditions.

5. I am responsible to timely notify my employer of any change that would make me or

any dependent ineligible for benefits.

6. By signing this application, I agree and consent to the recording and / or monitoring of

any telephone conversation between Anthem and myself.

I acknowledge that I have read the Significant Terms, Conditions and Authorizations, and I

accept such provisions as a condition of enrollment. I represent that the answers given to

all questions on this application are true and accurate to the best of my knowledge and I

understand they are being relied on by Anthem in accepting this application. I understand

that any misstatements or failure to report new medical information prior to my effective

date may result in a material change to benefits or rates. Any material misrepresentation

or significant omission found in this application may result in denial of benefits or

rescission or cancellation of my benefits.

Kentucky: Any person who knowingly and with intent to defraud any insurance company,

health maintenance organization, self-insured plan, or other person, files an application for

insurance or other form of health care coverage containing any materially false information

or conceals, for the purpose of misleading, information concerning any fact material thereto

commits a fraudulent insurance act, which is a crime.

I give this authorization for and on behalf of any eligible dependents and myself if covered

by the Plan. I am acting as their agent and representative.

Your health benefit plan will be administered by one of the following companies based

upon the state in which your employer is located:

In Indiana: Anthem Blue Cross and Blue Shield is the trade name of

Anthem Insurance Companies, Inc.

In Kentucky: Anthem Blue Cross and Blue Shield is the trade name of

Anthem Health Plans of Kentucky, Inc.

In Missouri: Anthem Blue Cross and Blue Shield is the trade name RightCHOICE®

Managed Care, Inc. (RIT), Healthy Alliance Life Insurance Company (HALIC) and HMO

Missouri, Inc. use to do business in most of Missouri. RIT and certain affiliates

administer non-HMO benefits underwritten by HALIC and HMO benefits underwritten by

HMO Missouri, Inc.

In Ohio: Anthem Blue Cross and Blue Shield is the trade name of

Community Insurance Company.

In Wisconsin: Blue Cross Blue Shield of Wisconsin (‘‘BCBSWi’’) administers the PPO

and indemnity policies; Compcare Health Services Insurance Corporation (‘‘Compcare’’)

administers the HMO and POS policies.

Thank you for choosing Anthem Blue Cross and Blue Shield.

9. Read the TERMS section above carefully before signing. Please review your application for errors or omissions.

By signing this, I am indicating that I have read and understand the language in the TERMS section of this application and agree to all of its terms.

Applicant Signature Date

Please complete the waiver on the next page if you and / or any eligible dependent are not enrolling.

A-77 8/06 LG-ASO

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I certify that I have been given an opportunity to apply for the employer’s health benefits plan, and after careful consideration, have decided not to take advantage of this offer. In the event I wish

to apply for such benefits hereafter, I may do so, subject to established procedures.

If I am declining enrollment for myself or my dependents (including my spouse) because of other health insurance coverage, I may in the future be able to enroll myself or my dependents in this plan,

provided that enrollment is requested within 31 days after other coverage ends. My dependent(s) or I may be subject to pre-existing condition restrictions or waiting periods specified in the group

benefit booklet, if a dependent or I are late enrollees. In addition, if I have a dependent as a result of marriage, birth, adoption or placement for adoption, I may be able to enroll myself and my dependents

provided that I request enrollment within 31 days after the marriage, birth, adoption or placement of adoption.

Already protected by coverage of:

10. Waiver of coverage for employee and / or any eligible dependent not enrolling

Check all that apply. Waiving:

Name of person waiving

Employer name

Health Dental Vision All

Spouse Parent None

Carrier: Anthem (give certificate/policy #) Other carrier (give name, ID #)




Employer name


Spouse Parent None





Employer name


Spouse Parent None





Employer name


Spouse Parent None


Applicant Signature Date




Employer name


Spouse Parent None


A-77 8/06 LG-ASO

4

_____________________________________ ___________________

PLYMOUTH COMMUNITY SCHOOL CORPORATION TELEPHONE 574-936-3115

Office of the Superintendent FAX 574-936-3160 Administration Office 611 Berkley Street Plymouth, IN 46563

Date: ________________________

PLEASE SIGN ME UP FOR DENTAL INSURANCE

Effective Date of Coverage: ______________________________

Name: ______________________________________________________

SSN: ______________________________________________________

Address: ______________________________________________________

City & Zip: ______________________________________________________

DOB: ______________________________________________________

Signature Date

_____________________________________ ___________________

PLYMOUTH COMMUNITY SCHOOL CORPORATION TELEPHONE 574-936-3115

Office of the Superintendent FAX 574-936-3160 Administration Office 611 Berkley Street Plymouth, IN 46563

Date: ________________________

PLEASE SIGN ME UP FOR VISION INSURANCE

Effective Date of Coverage: ______________________________

Name: ______________________________________________________

SSN: ______________________________________________________

Address: ______________________________________________________

City & Zip: ______________________________________________________

DOB: ______________________________________________________

Signature Date


INSURANCE VERIFICATION

Name: __________________________________________________________________

Job Title: _______________________________ Date Employed: ________________

□ I would like to participate in MASE Medical Insurance

□ I do not want to participate in MASE Medical Insurance

Reason: ___________________________________________________________

□ I would like to participate in the Dental Insurance Plan

□ I do not want Dental Insurance

Reason: ___________________________________________________________

□ I would like to participate in the Vision Insurance Plan

□ I do not want Vision Insurance

Reason: ___________________________________________________________

□ I would like to participate in the Life Insurance Plan

□ I do not want Life Insurance

Reason: ___________________________________________________________

______________________________________ Date: ___________________ Signature of Employee

PLYMOUTH COMMUNITY SCHOOLS

Keep Your Cash In Your Pocket

Section 125Benefits Summary

~ American Fidelity~qyAssuranceCompanyA member of the American Fidelity Groupl!ll

Dave Dillon, Account ManagerIndiana Branch Office8435 Georgetown Rd. #1100Indianapolis, IN 462681-800-638-4268

317-871-2480

Is Your Paycheck Saving You Money?The Section 125 Plan allows you to deduct needed benefits from gross earnings before taxes arecomputed. What that means is that current after-tax expenses for insurance products and benefits cannow be paid for with pre-tax dollars. Plus, the plan is available to you at no cost and you're alreadyeligible-all you have to do is enroll!

By implementing this plan, your employer is helping you reduce your taxes and increase your spendable income. The costsaving advantage of the plan is simple. Any benefit costs or insurance premiums you pay under the plan are paid on a pre-taxbasis.

wow-You Save $701

li(lfiiiJjii~i~:~j;i~11;~i~li~~illl~!f:~~':i"\~' Earning & Hours WITHOUT 8125 WITH 8125 Wii

Monthly Salary $2,000 $2,000Medical Deductions N/A ~250

Taxable Gross $2,000 $1,750Taxes (Federal & State @ 20%

) -400 -350Less Estimated FICA (7.65%) -153 ~133

Medical Deductions -250 N/A

Take Home Pay $1197 $1267

A Dependent Day Care Reimbursement Account is used to reimburseyourself for eligible dependent care expenses incurred to allow you towork or, if you are married~ your spouse to work or look for work. Youmay allocate up to $5,000 pre~tax per calendar year for reimbursement ofdependent care services ($2,500 if you are married and file a separate taxreturn).

An Unreimbursed Medical Expense Account may be used to reimburse yourself for eligible medical expensesincurred for yourself, your spouse, and your eligible dependents. Examples of eligible medical expenses mayinclude, but are not limited to medical deductibles, co-payments, prescriptions and other medical expenses notreimbursed by another source.

Example is for illustrative purposes only, Please consult YOUy tax advisorforactual tax savings.

Are You Saving Money OnDependent Day Care andOut-Of-Pocket Medical Expenses?You can direct a part of your pay, on a pre-tax basis, into special accountsthat can be used to reimburse yourself for Dependent Day Care expensesand/or Unreimbursed Medical expenses. As you incur a qualified DependentDay Care expense or an Unreimbursed Medical Expense, you submit theappropriate claim paperwork to American Fidelity for reimbursement ofyour expense.

How Can This Plan Help You?This iHustration shows the advantage of theSection 125 Plan in comparison to benefits without theplan. The sample paycheck with the Section 125Flexible Benefit Plan has $70 of more spendableincome per month!

If you are subject to FICA taxes, there might be a slightreduction in your social security benefit due to thereduction of FICA contributions.

Are You Protecting Your Promises? We all make promises to those that we hold dear. One such promise is to provide a good standard of living for our loved one. Disability income insurance plays an important part in helping you keep your word.

Can you aHord to go without your paycheck during the waiting period for your Long Term Disability (overage? Why not cover that risk with a disability plan that is designed to cover short-tenn disabilities? You need salary protection if you depend on your income. If disabled, would you still have to pay your mortgage/rent, utilities or car payment? Protect your most valuable asset: your ability to earn an income.

The policy has limitations, exclusions and waiting periods.

Do You Need Accident Protection? Did You Know? • Afatal injury occurs every 5 minutes and a disabling injury occurs every 1.3 seconds. I

• About 113,000 people died as a result of accidents in the U.S. in 2005.2

Consider a Limited Benefit Accident Only Insurance Policy Today • Benefit payments are made directly to you.

• Benefits paid regardless of other coverage.

• Individual and family plans available.

• Guaranteed renewability for the base plan for as long as you pay your premiums as required.

• Accident Disability Income Riders available to primary insured and spouse guaranteed renewable until age 70 for the primary insured.

• Wellness benefit for a Covered Person's annual routine physical exam, including immunizations and preventive testing.3

JSource: National Safety Council. Injury Facts®, 2007 Edition, page 2 2Source: National Safety Council. Injury Facts®, 2007 Edition, page 8 3The Policy must be inforcefor 12 continuous months for the Wellness benefit to he payable. This benefit does not apply to dental or eye exams and is payable once per policy per calendar year. This product is inappropriatefor people who are eligiblefor Medicaid coverage. This is a briefhighlight ofsome ofthe features ofthe product. The policy has limitations and exclusions. All benefits may not be available in all states. Your American Fidelity Representative can supply you with costs and complete details ofcoverage. The company has the right to change premiums by class. (AO-03 Series)

Cancer • BasIc FadsOverall Costs for Cancer

$206.3 Billion2It's afact - The survival rate for all cancers combined and for certain site-specificcancers has improved significantly since the 19705, due, in part, to both earlierdetection and advances in treatment. 1

However, the sad truth is that many Americans cannot afford to bear the expense of thesometimes costly screenings that could save so many lives. The overall cost of cancer was$206.3 billion in 2006: $78.2 billion for direct costs (medical expense) and $128.1 billionfor indirect costs.2

The American Fidelity limited benefit cancer insurance policy includes benefits for:

• Diagnostic Screenings • Transportation and Lodging

• Treatment • Optional Riders Available

• Facilities

Ifyou have been cancer diagnosed and treatment free for 10years, you can apply foIAmerican Cancer Society: Cancer Statistics 2005 powerpoint presentation.2American Cancer Society: Cancer Facts and Figures 2007, pg. 3This is a limited benefit cancer insurance policy. This product is inappropriate for people who are eligiblefor Medicaid coverage. This is a briefhighlight ofsome ofthefeatures o/the product. The policy has limitations, exclusions and waiting periods. All benefits may not be available in all states. The company has the right to changepremium by class, Your American Fidelity Representative can supply you with costs and complete details ofcoverage.

Do You Have Permanent,Portable Life Insurance?lYour employer may provide you with Group Life Insurance - but do you have permanent,portable life insurance that you can take with you after your employment ends?

Life Insurance At Retirement Can Be Very Costly. Secure your life insurance premium todaywith a permanent and portable plan.

PureLife benefits include:

Underwritten by

Texas life Insurance Company~A Metlife CompanySince 1901 I 900 WASHllIIGlOIII I POSI OFflef BOX 830 I WACO, T£~"S 16703-0830

• Permanent Life Insurance to age 121.

• Minimal cash value - Premiums dedicated primarily to the purchase of life insurance.

• Long premium guarantees2.

• Unique limited right to partial refund of premium if future premium required to continue coverage increases (conditions apply).

• PORTABLE when you leave employment.

1 Life insurance is not available for purchase under the Section 125 plan. See your American FidelityRepresentativefor more infOrmation.

2 After the guaranteed Period, premiums can be lower, the same or higher than the table premium.See the PureLife brochurefor details.

Policy Form: PRFNG-Nl-0708M129-C 1055 (expires 7/31110)

~American Fidelity~ eAssurance CompanyA member of the American Fidelity Group",

)(X~)(

ISTA~FinancialServices

PROGRAM

iT_.Secured Access Available to Review

Your Personal Account Status and History

SB-14433 f (olvmouth) )-0807

PLYMOUTH COMM SCHOOLS Employee Benefit Election/Salary Reduction Agreement

Emp # # = Number of Deductions Employer: PLYMOUTH COMM SCHOOLS Other Information: Employee: Social Security #: Address: Home Phone #: Email:

Plan Year Beginning: Ending:

I have elected participation in the following benefits:

Status # Effective Date Benefit/Company

Section 125 Before-Tax

After-Tax Payroll Deduct

Employer Paid

**** 403(b)/457(b)

Annuity Accident ***Flex **Cancer HOSPITAL/HOSPITAL Medical DENTAL VISION *Disability LIFE INSURANCE

Total

* This benefit will result in taxable income if selected on a before-tax basis. ** When indemnity premiums are pre-taxed, benefits paid in excess of the medical expenses incurred could be taxable *** Any amount in the Employer Paid column reflects an annual contribution.

Annuity amounts shown above are for information purposes only. This from is not an authorization to reduce salary for 403(b) and 457(b) plans. A 403(b) or 457(b) salary reduction from must be completed and submitted to the employer.

PLYMOUTH COMM SCHOOLS Employee Benefit Election/Salary Reduction Agreement

Emp # # = Number of Deductions Employer: PLYMOUTH COMM SCHOOLS Other Information: Employee: Social Security #: Address: Home Phone #: Email:

Plan Year Beginning: Ending:

Terms and Conditions

I hereby authorize the above payroll reductions as my contribution to my Employer’s Section 125 Cafeteria Plan.

I understand that:

1. Changes in the cafeteria plan elections (other than with respect to the Health Savings Account) can only be made at the end of the plan year unless due to and consistent with a valid status change (e.g., change in legal marital status; change in number of dependents; change in employment status; dependent satisfies or ceases to satisfy dependent eligibility requirements; residence change, cost or coverage changes) and such other events as would permit a revocation or change of election under IRC 125 regulations. Participation in this plan will automatically cease upon termination of employment. In most cases NO change may be made in the Medical Expense Reimbursement Account except for termination of participation of employment. For special rules affecting your plan, please contact your employer. FICA taxes are not paid on Section 125 salary reduction. Therefore, your social security benefits at retirement may be reduced. Unused funds remaining in the flex spending accounts at the end of the current plan year will be forfeited.

2. Execution of this benefit election/salary reduction agreement does not automatically institute insurance coverage; in most instances an application for insurance must be completed. Premiums charged for insurance coverage may be adjusted by the carrier issuing the contract and my “take-home” pay may be higher or lower depending on the selections made.

If I have elected the Health Savings Account benefit, I certify that I have met all the Health Savings Account eligibility requirements, which have been separately disclosed to me, and that I will notify the Employer immediately in writing if I cease to meet any of the conditions for Health Savings Account eligibility during any month of the plan year.

This authorization replaces any previous authorization I have made.

Date: ________________________ Signature of Employee: _________________________________________

____________________________________

_________________

PLYMOUTH COMMUNITY SCHOOL CORPORATION ADMINISTRATIVE GUIDELINES

8442 ON-THE-JOB INJURY

It is the goal of Plymouth Community School Corporation that all employees receive prompt medical treatment if they have sustained a work-related injury. We have designated LifePlex Urgent Care as our Occupational Provider for prompt and compassionate treatment for our employees.

If you have sustained a work-related injury, the following steps must be followed:

1. Complete an Indiana Worker’s Compensation First Report of Employee Injury, Illness Form (Form 8442 F1). This may also be obtained from your building principal, supervisor or administration building representative.

2. An Employers Authorization for Care form will be completed by your building principal, supervisor or administration building representative. This form must be taken with you to LifePlex Urgent Care in order to receive medical treatment.

3. A photo ID and drug screening with alcohol test will be required at time of medical treatment.

4. Return all paperwork received by Lifeplex Urgent Care to the Administration Office as soon as possible after receiving treatment.

LifePlex Urgent Care Office Hours Monday thru Friday - 9:00 am to 7:00 pm Saturday and Sunday - 9:00 am to 3:00 pm

They are a walk-in clinic with no appointment required. (574) 941-1000

(Employees injured after LifePlex Urgent Care’s normal business hours may go to the emergency room for treatment or may wait until 9:00 a.m. the next day to seek treatment.)

If the Corporation does not believe the injury entitles the employee to receive worker compensation benefits, it shall so notify the employee and the Worker Compensation Board within thirty (30) days of the date at which the alleged disability begins, in accordance with the procedures prescribed by the Board. (I.C. 22-3-7)

Revised 2/11

By signing below I acknowledge that I have been given and understand the Administrative Guidelines for #8442 - On-The-Job Injury for Plymouth Community School Corporation.

Printed Employee Name PLEASE SIGN AND RETURN TO THE ADMINISTRATION

____________________________________ BUILDING. Signature

Date

EMPLOYEE COPY

PLYMOUTH COMMUNITY SCHOOL CORPORATION ON-THE-JOB INJURY CONTACT LIST

PLYMOUTH HIGH SCHOOL Building Principal / (574) 780-6709

LINCOLN JUNIOR HIGH SCHOOL Building Principal / (574) 780-4539

RIVERSIDE INTERMEDIATE SCHOOL Building Principal / (574) 780-3388

JEFFERSON ELEMENTARY SCHOOL Building Principal / (574) 780-4554

MENOMINEE ELEMENTARY SCHOOL Building Principal / (574) 780-1811

WASHINGTON ELEMENTARY SCHOOL Building Principal / (574) 780-0230

WEBSTER ELEMENTARY SCHOOL Building Principal / (574) 529-3157

MAINTENANCE DIRECTOR (574) 780-0993

TRANSPORTATION DIRECTOR (574) 780-0999

DIRECTOR OF NURSING (574) 767-0877

FOOD SERVICES DIRECTOR (574) 767-0157

TECHNOLOGY DIRECTOR (574) 780-3744

CORPORATION TREASURER (574) 780-0995

SUPERINTENDENT (574) 780-3891

ASSISTANT SUPERINTENDENT (574) 249-2334

and investment elections.

_________________________________________ ___________________________________________

_________________________________________ ___________________________________________

This is an official School document. Salary deferral contributions will NOT be made to the 403(b) Plan on your behalf until you have completed and returned this agreement to the School, as well as the Lincoln Financial on-line enrollment forms designating your beneficiary and investment elections.

PLYMOUTH COMMUNITY SCHOOL CORPORATION 403(b) PLAN SALARY REDUCTION AGREEMENT

Employee Name (First, M.I., Last) Employee's Date of Birth

Employee Address (Street, City, State, ZIP)

_______________________________ Employee Social Security Number Number of Pay Periods Per Year

This Salary Reduction Agreement ("Agreement") is entered into between the above-described employee ("Employee") of Plymouth Community School Corporation and Plymouth Community School Corporation ("School") in order for salary deferral contributions to be made to the Plymouth Community School Corporation 403(b) Plan ("Plan") under Section 403(b) of the Internal Revenue Code (“Code”).

I. AUTHORIZATION TO MAKE SALARY DEFERRAL CONTRIBUTIONS

I hereby direct the School to reduce my salary by the amount completed below, and to forward this salary deferral contribution to Lincoln Financial. I understand that I may choose for this contribution to be deducted from my salary on a pre-tax basis, on a post-tax basis as a Roth contribution, or in part on a pre-tax basis and in part on a post-tax Roth contribution basis.

Flat Dollar Amount Per Pay Period (enter a whole dollar amount)

Pre-Tax Contributions $_____________

Post-Tax Roth Contributions $_____________

Total Dollar Amount $_____________

II. EFFECTIVE DATE AND DURATION OF AGREEMENT

I understand that this Agreement will take effect as soon as administratively practicable following the date I complete this Agreement and return it to the School’s Business Office, and will remain in effect until I change or terminate it by submitting a new Agreement. I understand that I may make changes in my elective deferral amount at any time, which will be effective the earlier of the next September 1 or January 1. I understand that I may stop contributions at any time. I acknowledge that this Agreement applies only to salary not yet paid or made available to me. I understand that the School may reduce or discontinue this Agreement at any time if necessary to comply with the applicable provisions of the Internal Revenue Code.

III. TERMINATION OF AGREEMENT

I want to stop my salary deferral contributions to the Plymouth Community School Corporation 403(b) Plan effective as soon as administratively practicable after I have completed this Agreement and returned it to the School’s Business Office.

IV. SIGNATURES

I have read the information on the back side of this form and represent that I understand the same. I agree to follow the rules and procedures of the Plymouth Community School Corporation 403(b) Plan and Lincoln Financial.

Date Employee's Signature

Date Signature of Authorized School Representative

I/2193085.2

V. EMPLOYEE REPRESENTATIONS AND UNDERSTANDINGS

Applicable Contribution Limits

• I understand that my salary reduction contributions under this Agreement cannot exceed the contribution limits under Code Section 402(g) or 415(c) (as explained below), except as permitted by Code Section 414(v) allowing age 50 catch-up contributions (as explained below).

• I understand that Code Section 402(g) limits my salary reduction contributions under this Agreement to a "dollar limit." The general dollar limit is $16,500 for calendar year 2009 (this dollar limit will be adjusted by cost of living increases thereafter). However, my actual dollar limit may be higher than the general dollar limit if I will be 50 years old (or older) by the end of the calendar year.

• If I will be at least 50 years old by the end of the calendar year, I understand that I may make additional "catch-up" salary reduction contributions above the general dollar limit. These additional catch-up salary reduction contributions, which are referred to as "age 50 catch-up contributions," are provided under Code Section 414(v). I understand that the amount of the age 50 catch-up contributions that I may make above the general dollar limit is up to an additional $5,500 for 2009 (this dollar amount will be adjusted by cost of living increases thereafter).

• I understand that the dollar limit, with all appropriate adjustments described above, applies to any pre-tax or post-tax Roth contributions I make in a calendar year to any retirement plans in which I participate (not including PERF, TRF, deferred compensation plans or flexible benefit plan contributions), including plans maintained by other employers.

• I understand that, if my salary reduction contributions to this Plan and to other retirement plans exceed the applicable dollar limits described above in any calendar year, the excess will be taxable both in the year the contribution was made and in the year of distribution unless I timely request to have the excess returned to me. To have the excess returned to me, I must notify the School or Lincoln Financial of the excess before March 1 of the year following the year in which the excess contribution was made (e.g. March 1, 2009 for excess amounts deferred in 2008). If the notice is timely given, Lincoln Financial will distribute the excess amount of the contribution (with any accrued earnings) to me on or before April 15 of the year following the excess contribution.

• I understand that my salary reduction contributions to the Plan and other retirement plans for each year are also limited, except as permitted under Code Section 414(v) allowing age 50 catch-up contributions, by the general rules of Code Section 415 to the lesser of $49,000 for 2009 (this dollar amount will be adjusted by cost of living increases thereafter) or 100% of compensation.

Additional Representations

• I understand that this Agreement is legally binding and irrevocable with respect to amounts earned while the Agreement is in effect. Therefore, amounts previously withheld from my pay under the terms of this Agreement cannot be returned to me unless I am eligible for a distribution under the terms of the Plan.

• I authorize the School to release to or obtain from Lincoln Financial any information that it may reasonably require in order to calculate my contribution limits or to administer my accounts under the Plan.

• I understand that nothing contained in this Agreement shall be deemed to constitute an employment agreement, and nothing contained herein shall be deemed to give me any right to continued employment with the School.

• I acknowledge that the School does not warrant the performance or the appropriateness of any investment and will not be responsible for any penalties or tax consequences resulting from this Agreement.

• I agree to follow the rules and procedures of the Plan, the School, and Lincoln Financial.

FOR OFFICE USE ONLY: To be completed by Business Office Representative:

Confirm Lincoln Enrollment Forms Completed Date of First Payroll Reduction:

I/2193085.2

__________________________________________________________________________________________

Notice Of Election For Annualized Salary PLEASE RETURN BY ___________________

This is to notify the Plymouth Community School Corporation that I have elected, beginning with the ____________________ school year, to have the salary fro the approximately 10 month period during which I actually perform services paid out over a 12 month period. The payments will be made in 26 equal payments, or 21 equal payments of 1/26th of the contract until the 2nd pay in June, at which time, the remaining contract amount will be paid in its entirety.

In the event a separation from service occurs before the end of the 12 month payment period, I will be entitled to an additional payment for the amount I have actually earned from the beginning of the 12 month pay period until the date of my separation from service, but which not has yet been paid. This additional payment will be included in my final paycheck. For this purpose, “separation from service” shall have the same meaning as that term is defined in section 1.409A-1(h) of the Treasury Regulations. (Generally, the regulations state that a “separation of service” occurs when the employees dies, retires, resigns, or otherwise has a termination of employment with the employer.)

This notice is irrevocable for any particular school year, and may not be changed or withdrawn after the beginning of the school year in which I am working. This notice will be effective for the _________________ school year, unless I choose to change my election. If I choose not to have my salary deferred in any future school year and be paid only during the period that I actually perform services, I will so notify the employers in writing prior to beginning work for that school year.

This notice shall have not effect if not submitted to the district prior to the time I begin working for the __________________ school year.

I HAVE ELECTED 26 EQUAL PAYS.

Signature: _______________________________________________ Date: _________________________

Printed Name: ____________________________________________

------------------------------------------------------------OR----------------------------------------------------------------------

I HAVE ELECTED 21 EQUAL PAYMENTS EACH 1/26TH WITH EARLY PAY OUT ON 2ND PAY IN JUNE. PLEASE SEE MASTER CONTRACT FOR DETAILS (PAGES 16-17).

Signature: _______________________________________________ Date: _________________________

Printed Name: ____________________________________________

------------------------------------------------------------OR----------------------------------------------------------------------

I HAVE ELECTED TO HAVE THE 21 PAY SCHEDULE.

Signature: _______________________________________________ Date: _________________________

Printed Name: ____________________________________________

Approved by the State Board of Accounts, 2008

ENROLLMENT FORM FOR NEW MEMBERS State Form 37680 (R12 / 2-08)

INSTRUCTIONS:

This form is for new members of the Indiana State Teachers’ Retirement Fund. Pre-existing members wanting to make changes to their account should use the “Request for Member Data Change” form State Form 43567) that is available from our offices. The employer must sign to certify that the member meets eligibility requirements.

Please forward the completed form to the retirement system within five (5) days of the teacher’s date of employment. You must complete all items on this form, using “N/A” where not applicable. If an employee is already a member, we do NOT need a new membership record.

PLEASE USE BLACK INK ONLY

Indiana State Teachers’ Retirement Fund 150 West Market St., Suite 300

Indianapolis, IN 46204-2809 Telephone: (317) 232-3860 / (888) 286-3544

Home page: http://www.in.gov/trf

PRIVACY NOTICE

Your Social Security number is requested by this agency in accordance with the require-ments of IRS Code 3405. Disclosure is mandatory; this form will not be processed without this information.

TRF Number (Office Use Only)

MEMBER INFORMATION Social Security Number Marital Status

Married Single

Gender

Male Female

Date of Birth (mm/dd/yyyy)

First Name MI Last Name

Address Home Phone Number

Other Phone Number

Email Address

City State Zip Code

You are required to submit a copy of your Social Security Card and Birth Certificate from your Public Health Department. If you do not submit a copy of your Social Security Card and Birth Certificate with this form, you must forward one to the Teachers’ Retirement Fund as soon as possible.

PREVIOUS MEMBERSHIP INFORMATION (To be completed by member) Have you ever served on active duty in the Armed Forces of the United States? YES NO

Have you previously been employed in a position covered by the Indiana Public Employees Retirement Fund? YES NO

If yes, are you receiving benefits from the Indiana Public Employees Retirement Fund? YES NO

Have you previously been employed in a position covered by the Indiana State Teachers’ Retirement Fund? YES NO

If yes, are you receiving benefits from the Indiana State Teachers’ Retirement Fund? YES NO

Have you ever served in an out-of-state teaching position? YES NO

BENEFICIARY INFORMATION

Primary Secondary Social Security / Tax I.D. Number Beneficiary Date of Birth Relationship




In accordance with the provisions of Ind. Code § 21-6.1-4-8, I designate the above as my primary beneficiary. If the primary beneficiary herein nominated shall survive me, he or she shall receive all funds due to a beneficiary from my participation in the Teachers’ Retirement Fund. If the primary beneficiary shall not survive me, then the secondary beneficiary shall receive such funds; if neither shall survive me, then the beneficiary shall be my estate. I understand that I have the right to designate “NONE” as secondary beneficiary or both primary and secondary beneficiary. If no designation is made, any death settlement due would be payable to my estate. I reserve the right to change the primary or secondary beneficiary at any time prior to retirement by filing a “Data Change Form” with the Board of Trustees of the Indiana State Teachers’ Retirement Fund. Signature of Member Date of Signature (mm/dd/yyyy)

CURRENT EMPLOYMENT INFORMATION (To be completed by employer) Employer Unit Number Name of Employer Date Employed (mm/dd/yyyy)

EMPLOYER CERTIFICATION Pursuant to Title 515 IAC et seq., by signing below, you are verifying that the above individual is qualified to serve as a teacher.

Authorized Signature Title Date of Signature (mm/dd/yyyy)

PRIVACY NOTICE

All Social Security Numbers are requested by this agency in accordance with the requirements of the Internal Revenue Code. Disclosure is mandatory and this form will not be processed without this information.

State Form 34413 (R6/09-04)

INSTRUCTIONS: 1) Please print or type in black ink. 2) Complete all information. Incomplete forms will be returned. 3) Return the completed and signed form directly to PERF. Do not return the instruction pages.4) DO NOT FAX. Facsimile copies are not acceptable.

STEP 1: ENROLLMENT INFORMATION

Social Security Number Date of Birth (mm/dd/yyyy)

First Name MI Last Name

Address

City State Zip Code

Home Telephone Number Other Telephone Number

E-mail Address

MALEGENDER FEMALE CURRENT MARITAL STATUS MARRIEDSINGLE

STEP 2: For Employer Use Only Date of Full-time Employment in this PERF-covered Position, and start of Mandatory Contributions (mm/dd/yyyy)

Position or Title

YES NOIs this an Elected Position? Has this employee ever been a member of PERF before? YES NO

Employer Name Employer Phone Number

Employer Address

City State Zip Code

Employer Account Number Title of Authorized Agent

I have verified that the Social Security Number on this form is the same as the number used on our payroll and reported to the Internal Revenue Service for tax purposes.

Signature of Authorized Agent Printed Name of Authorized Agent

Page 1 of 2

http://www.in.gov/perf/pe/pdf/form_nmsf.pdf

http://www.in.gov/perf/pe/pdf/form_nmwi.pdf

http://digitalassets.ind.net/vss-bin/vss_SR/PERF/media_sync

Member Name (Last, First, Middle Initial) Social Security Number

STEP 3: BENEFICIARY INFORMATION (Must be Signed and Dated by the Member)Attach Additional Copies of this Page if Necessary

Additional pages are attached. YES NO

Primary Beneficiary or Beneficiaries Beneficiary Name (Last, First, Middle Initial) Social Security Number or Tax ID

Date of Birth (mm/dd/yyyy) Relationship to Member

Street Address City State Zip Code

Beneficiary Name (Last, First, Middle Initial) Social Security Number or Tax ID



Contingent Beneficiary or Beneficiaries Beneficiary Name (Last, First, Middle Initial) Social Security Number or Tax ID



Beneficiary Name (Last, First, Middle Initial) Social Security Number or Tax ID



In accordance with the provisions of Indiana Code § 5-10.2-3, I designate my beneficiary or beneficiaries of my Annuity Savings Account as shown above. I understand that this designation of beneficiary supersedes and replaces any prior designation of beneficiary or beneficiaries that may have been made in the course of this or any prior employment in a PERF-covered position with any other employer. If the primary beneficiary or beneficiaries herein designated survive me, they shall receive the funds, if any, that are payable by the fund to a designated beneficiary. If the primary beneficiary or beneficiaries do not survive me then the contingent beneficiary or beneficiaries shall receive such funds. If none survive me, then the beneficiary shall be my estate. If no designation is made, any death benefit due would be payable to my estate.

I reserve the right to change the primary or contingent beneficiaries at any time prior to retirement by filing a Change of Beneficiary form with the Board of Trustees of the Fund. Such a change must be received and accepted by the fund for it to become effective.

Signature of Member Printed Name Date

Membership Record Page 2 of 2State Form 34413 (R6/09-04)

http://www.in.gov/perf/pe/pdf/form_nmsf.pdf

http://www.in.gov/perf/pe/pdf/form_nmwi.pdf

http://digitalassets.ind.net/vss-bin/vss_SR/PERF/media_sync

FFA1 401 NONERISA (05/11) Page 1

Enrollment Form – Corporate Financial Freedom Account (Exclusive) Variable AnnuityMoney Purchase, Profit Sharing or IRC §401(k) Plan – NON-ERISA Account Number _________________

1 Employer/Plan Name Please complete the following:

Name of Employer Plan Name Employer Group Number

Street Address City or Town State Zip Code

2 Participant Identification

Participant Name Social Security Number Date of Birth


oSingle oMaleMarital Status: oMarried Sex: oFemale U.S. Citizen: o Yes o No If no, specify Country of Citizenship _______________

Home Telephone Number Work Telephone Number Most convenient Time/Place to call

Participant Information (to be provided by Plan Administrator for plans using MetLife RetireServe program only)

Employment Date Plan Participation Date Participant Annual Compensation

3 Replacement (Must be completed)(a) Do you have any existing life insurance or annuity contracts? o Yes o No

(If “Yes,” applicable disclosure and replacement forms must be attached.)

(b) Will the annuity applied for replace or change one or more existing annuity or life insurance contracts? o Yes o No (If “Yes,” applicable disclosure and replacement forms must be attached. If “No,” proceed to next section.)

Note: Replacement includes any surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or life insurance contract in connection with this application.

4 Beneficiary DesignationIndicate below the beneficiary you wish to designate to receive any and all benefits payable from the plan on account of your death. Please complete a Beneficiary Designation form if you would like to designate more than one primary or contingent beneficiary. The following may not apply if this is a church or governmental plan. If you are currently unmarried, any designation of a primary beneficiary you make will cease to be effective immediately upon your marriage. If you are currently married or separated and wish to make a primary beneficiary designation for someone other than your spouse, you must complete and attach to this enrollment form a separate Beneficiary Designation form in which you waive your right to the qualified pre-retirement survivor annuity provided by the plan and your spouse must give his or her consent to such waiver. Note if you are under the age of 35, this designation will become invalid on the first day of the plan year in which you reach age 35.Primary Beneficiary (For married participants: if other than spouse–complete Beneficiary Designation form)

oMr. oMrs. oMs.First Name, Middle Initial, Last Name Relationship to Participant Date of Birth Social Security Number

Mailing Address if different from Section 2: Number, Street, City or Town, State and Zip Code

Contingent BeneficiaryoMr. oMrs. oMs.First Name, Middle Initial, Last Name Relationship to Participant Date of Birth Social Security Number

Mailing Address if different from Section 2: Number, Street, City or Town, State and Zip Code


5 (a) Contribution (Pre-Tax) Election (Complete for 401(k) plans only . Generally, does not apply to governmental plans.) If an election is made below, such election revokes any election made in a prior period.

o I elect to participate in the 401(k) plan identified above. I authorize my employer to withhold a portion of my pay and make pre-tax contributions to the plan according to this election. I understand amounts deferred under this election will be exempt from Federal income tax but subject to FICA payroll taxes. This election is effective with the payroll beginning on __________ and shall remain in effect until modified or revoked. Complete one of the following: I elect to contribute ___________% of my pre-tax pay per pay period.

OR I elect to contribute $ ______________of my pre-tax pay per pay period.

o I do not wish to make pre-tax contributions at this time.

(b) Optional Payroll Deduction (After-Tax) Election (Complete only if your plan allows employee after-tax contributions.) If an election is made below, such election revokes any election made in a prior period.

o I authorize my employer to deduct a portion of my pay and make after-tax contributions to the plan according to this election. I understand amounts deducted under this election will be subject to both Federal income tax and FICA payroll taxes. This election is effective with the payroll beginning on _______________ and shall remain in effect until modified or revoked.

Complete one of the following: I elect to contribute ___________% of my after tax pay per pay period. OR I elect to contribute $ ______________of my after tax pay per pay period.

o I do not wish to make after-tax payroll deductions at this time.o Employee after-tax payroll deductions not allowed..

6 Financial Disclosure

(1) Number of Dependents: ______ Ages: _______________(2) Federal Tax Bracket: ______________________ %

(3) Estimated Annual Income (Not including this investment): $ __________________________________

(4) Net Worth (Assets less liabilities): $ _____________________________________________________

(5) Liquid Net Worth: $ ______________________ (Those assets that can be turned into cash quickly and easily, less liabilities. Include the amount of this investment. Exclude personal

property, personal residence, real estate, business equity, home furnishings and autos.)

(6) Prior Investment Experience (select all that apply): qMutual Funds _______ years qStocks _________ years qBonds ________ years qMoney Market ______ years qCD’s __________ years qVariable Life/Annuity ________ years qOptions ___________ years qMargin ________ years qHedge Funds ______________ years qLP’s ______________ years qOther _________ qNone

(7) Investment Objective (select one) (the following investment objectives are arranged from low to high risk): qCapital Preservation: seeks income and stability with minimal risk qIncome: seeks current income over time qGrowth and Income: seeks capital appreciation over long term combined with current dividend income qGrowth: seeks capital appreciation over long term qAggressive Growth: seeks maximum capital

(8) Time Horizon for Investments within this Account (select one): qShort Term (1-4 Years) qIntermediate Term (5-9 Years) qLong Term (10+ Years)

(9) Risk Tolerance (select one): qConservative qConservative to Moderate qModerate qModerate to Aggressive qAggressive


6 Financial Disclosure (cont’d.)

(10) Source of Funds (select all that apply): qSalary Reduction/Bonus q401(k) q403(b) q457(b) qRollover Pension Assets qTraditional IRA qRoth IRA qSEP qSimple IRA qAnnuity Contract qLife Insurance Policy Other (please explain): _______________________________________________________________

(11) Purpose of Annuity Contract (Choose One): qIncome – Primary purpose is to satisfy income needs in the future through annuitization or withdrawals qEstate Planning – Primary purpose is to transfer wealth to beneficiaries upon death. qWealth Accumulation – Primary purpose is long term accumulation of value without express desire for “retirement income” or

“estate planning”. qRetirement Planning – Primary purpose is long term accumulation of value specifically to meet or supplement income needs upon

retirement.

Other – ____________________________________________________________________________________________

(12) Do you anticipate making a withdrawal, other than pursuant to a systematic withdrawal plan, before you attain age 59½ qYes qNo

(13) Are you or an immediate family member associated with an FINRA member firm? qYes qNo

(14) Are you a member of the military services or a dependent of a member of the military services: qYes qNo (If yes, please leave the important information for Members of the Military Services and their Dependents with the Applicant)


7 Allocation of Contributions(a) Allocations

Indicate the percentage of your initial contribution to be allocated to each funding choice. Percentages must be in whole numbers. This allocation will apply to future contributions unless you make a change. You may change your allocation at any time. (Total of both columns must equal 100%.)

(b) Optional Automated Investment Strategy [Item (a) must be completed.] o Equity Generator® MetLife Stock Index Division

Funding Options% Fixed Interest Account% American Funds Bond Fund% Barclays Capital Aggregate Bond Index% Fidelity VIP Investment Grade Bond% Met/Franklin Low Duration Total Return% PIMCO Inflation Protected Bond% PIMCO Total Return% Western Asset Management U.S. Government% Western Asset Management Strategic Bond Opportunities% Lord Abbett Bond Debenture% American Funds Growth Fund% American Funds Growth-Income Fund% BlackRock Large Cap Value% BlackRock Legacy Large Cap Growth% Calvert VP SRI Balanced% Davis Venture Value% FI Value Leaders% Fidelity VIP Equity-Income% Fidelity VIP Growth% Janus Forty% Jennison Growth% Legg Mason ClearBridge Aggressive Growth% Met/Franklin Income% Met/Franklin Mutual Shares% MetLife Stock Index% MFS® Total Return% MFS® Value% Oppenheimer Capital Appreciation% T. Rowe Price Large Cap Growth% Harris Oakmark International % Met/Templeton Growth% MFS® Research International

Funding Options% Morgan Stanley EAFE® Index% Oppenheimer Global Equity% Calvert VP SRI Mid Cap Growth % Lazard Mid Cap% Met/Artisan Mid Cap Value% MetLife Mid Cap Stock Index% Morgan Stanley Mid Cap Growth% Neuberger Berman Mid Cap Value% T. Rowe Price Mid Cap Growth% American Funds Global Small Capitalization Fund% Invesco Small Cap Growth% Loomis Sayles Small Cap Core% Loomis Sayles Small Cap Growth% Neuberger Berman Genesis% Russell 2000® Index% T.Rowe Price Small Cap Growth% Clarion Global Real Estate% RCM TechnologyPortfolios That Invest in Exchange Traded Funds

% SSgA Growth and Income ETF% SSgA Growth ETF

MSF Asset Allocation Portfolios% MetLife Conservative Allocation% MetLife Conservative to Moderate Allocation% MetLife Moderate Allocation% MetLife Moderate to Aggressive Allocation

MIST Asset Allocation Portfolios% American Funds® Moderate Allocation Portfolio% American Funds® Balanced Allocation Portfolio% American Funds® Growth Allocation Portfolio% MetLife Aggressive Strategy Portfolio

MIST Fund of Funds% Met/Franklin Templeton Founding Strategy

Total of both columns must equal 100%.


8 SignaturesI hereby represent my answers to the above questions to be correct and true to the best of my knowledge and belief. I understand and acknowledge that all payments and account values, when based on the investment experience of the Separate Account, are not guaranteed. I understand that my employer’s plan document may impose restrictions on distributions. Further, I understand that I must contact the plan administrator/trustee to determine when and/or under what circumstances I am eligible to receive distributions.

I have received “Making an Informed Decision,” MetLife’s disclosure form describing the features of deferred variable annuities, and have been informed of these features and the other information disclosed in the form regarding my proposed annuity purchase.

Participant Signature City and State where signed Month/Day/Year

Signature of Witness (Licensed Representative) Plan Administrator Signature

City and State where signed Month/Day/Year

9 Account Representative/Manager Information

(a) Do you have any existing life insurance or annuity contracts? o Yes o No (If “Yes,” applicable disclosure and replacement forms must be attached.)

(b) Will the annuity applied for replace or change one or more existing annuity or life insurance contracts? o Yes o No (If “Yes,” applicable disclosure and replacement forms must be attached. If “No,” proceed to next section.)

Note: Replacement includes any surrender, loan, withdrawal, lapse, reduction in or redirection of payments on an annuity or life insurance contract in connection with this application.Are you licensed in the state of signing? o Yes o No

Schedule of Ongoing Contributions (based on contribution types allowed under the employer’s plan):

Employer Basic $ ________ X _______ (times/yr.) Employee Pre-Tax $ ________ X _______ (times/yr.) Employee After-Tax $ ________ X _______ (times/yr.) Employer Matching $ ________ X _______ (times/yr.) Employer IRC 414(h) “Pick–Up‘‘ (gov’t. plans only) $ ________ X _______ (times/yr.)

• All answers are correct to the best of my knowledge.• I have provided the Participant with MetLife’s Notice of Privacy Policies and Practices, prior to or at the time he/she

completed the enrollment form.• I am properly FINRA registered and licensed in the state where the Participant signed this enrollment form.• I personally saw the participant when the enrollment form was completed and each question was asked and answered as

recorded. All answers are correct to the best of my knowledge.• I have delivered the Producer Compensation Disclosure form (only applicable for business sold by MetLife, NEF, MLR and

P&C producers).• In each case where MetLife is sponsored or endorsed by an association (or pays such association for marketing/

communications support or for participating in association events), and I am enrolling or selling to an employee of such association (or to an employee whose employer is a member of such association), I have provided the employee with the approved Member Access and Communications Disclosure form specific for such case.

• I have delivered to the Proposed Owner “Making an Informed Decision,” MetLife’s disclosure form describing the features of deferred variable annuities.

• Based on information available from the participant, I believe this enrollment is appropriate and suitable.

Signature Print Full Name

Producer Identity Number Date

FORM DATE: May 2011Metropolitan Life Insurance Company

New York, NY

Questions? Call our National Service Center at 1-866-747-3416.

Security Benefit Health Reimbursement Arrangement (HRA) Indiana VEBA Plan

Employee Enrollment Form

®

32-90250-03 2011/01/11 (1/3)

Participant Name_____________________________________ ___________________________________ ______ ❍ Male ❍ Female Last First MI

Social Security Number ___________________________________________________

Mailing Address _________________________________________________ _____________________ ______ ______________________ Street Address City State ZIP Code

Residential Address_________________________________________________ _____________________ ______ ____________________ (if different from mailing address) Street Address City State ZIP Code

Daytime Phone Number ___________________________________ Home Phone Number __________________________________

Date of Birth__________________________ Date of Hire __________________________ ❍ Married ❍ Unmarried (mm/dd/yyyy) (mm/dd/yyyy)

E-mail Address ______________________________________________________________________________________________________

Complete the entire form to establish a new VEBA Account. Provide your employer a copy of this form. Please type or print in black ink.

1. Complete the entire form to establish a new VEBA Account. 2. Provide your employer a copy of this form. 3. If you have moved in the last 6 months or changed your name in the last 12 months, please include a completed

Form W9 with this enrollment. For information about the investments, a prospectus, fund fact sheets, or quarterly performance reports, visit our website at www.securitybenefit.com/Indiana.

Instructions

2. Provide Participant Information

Employer Group Name (required) _________________________________ Employer Plan Number (if known) __________________

1. Provide Employer Information

The default fund for participants who do not select an investment option for their existing account balance orfuture contributions will be the age appropriate T. Rowe Price Retirement fund. The fund will be selected based upon the year the client attains age 65. If the client is age 65 or over, or a date of birth is not indicated,the T. Rowe Price Retirement Income fund will be used.

3. Provide Investment Directions

_______ % Alger Midcap Growth Fd Cl A _______ % American Funds EuroPacific

Growth A _______ % American Funds Growth Fund

of America A _______ % American Funds Income Fund

of America A _______ % American Funds Washington

Mutual Invs A _______ % Artisan Mid Cap Value Fd

Investor Shs _______ % Baron Small Cap Fund _______ % BlackRock Fds Index Eq Cl A _______ % BlackRock Intl Opp Cl A _______ % BlackRock Mid-Cap Val Eq A _______ % Calvert Income A _______ % Calvert Social Inv

Fd Equity A _______ % Davis New York Venture A _______ % Fidelity Adv Mid Cap Stk Cl A

_______ % First Eagle Global Fund Class A _______ % Invesco Small Cap Growth

Fund - A _______ % JP Morgan Mid Cap

Value A Shs _______ % Loomis Sayles Fds Bond Fd Cl

Admin Tr I _______ % Lord Abbett Mid Cap Value

Fund Cl A _______ % Managers Cadence Emerging

Companies Adm _______ % Nationwide S&P 500 Index A _______ % Oppenheimer Global

Allocation Fund _______ % Oppenheimer Global Fund A _______ % Oppenheimer Main Street Fund

Class A _______ % PIMCO Funds Total Return Fund

Class A _______ % Pioneer Growth Opportunities A

_______ % Pioneer High Yield Fd A _______ % Royce Low Priced Stock Service _______ % Royce Total Return Service _______ % Security Benefit Fixed _______ % T. Rowe Price Retirement

2010 - R _______ % T. Rowe Price Retirement





Income - R _______ % Templeton Foreign Fund

Class A _______ % Touchstone Mid Cap Growth A Must Total 100%

32-90250-03 2011/01/11 (2/3)

I have read and understand the information on this form.

x__________________________________________________________________________________________________ __________________ Signature of Participant Date (mm/dd/yyyy)

x__________________________________________________________________________________________________ __________________ Authorized Plan Administrator Signature Date (mm/dd/yyyy)

5. Provide Signatures

For additional Qualified Dependents, please attach a separate list to the end of this enrollment form. For a definition of “Qualified IRS Dependent” see www.irs.gov.

4. Provide IRS Qualified Dependent Information

Dependent Name Social Security No. DOB (mm/dd/yyyy) Relationship to Participant

1.

2.

3.

4.

5.

6.

7.

8.

Transactions may be requested via telephone, Internet, or other electronic means by the Participant based on instructions of the Participant. Reasonable procedures have been established by Security Distributors, Inc. to confirm that instructions communicated by telephone are genuine and may be liable for any losses due to fraudulent or unauthorized investors if it fails to comply with its procedures. Neither the Fund nor Security Distributors, Inc. will be liable for any loss, liability, cost or expenses arising out of any telephone request, provided the procedures were followed. Thus, a stockholder may bear the risk of loss from a fraudulent or unauthorized request.

Set Up Electronic Privileges

– I hereby acknowledge that I have been provided a Plan Summary from my employer which describes the new Security Benefit Health Reimbursement Arrangement (HRA) Indiana VEBA Plan.

– If I choose not to complete Section 3: Provide Investment Directions, I further understand that, as a default, monies invested into my account will be allocated to the age appropriate T. Rowe Price Retirement fund, as explained in Section 3 until such time as I elect to contact the Retirement Service Center at 1-866-740-7677 or by accessing the web site at https://emjay.gwrs.com to make an account change.

– Withdrawal restrictions – I understand that the Internal Revenue Code (the “Code”) and/or my employer’s Plan Document may impose restrictions on transfers and/or distributions. I understand that I must contact the Plan Administrator to determine when and/or under what circumstances I am eligible to receive distributions or make transfers.

Disclosures

x__________________________________________________________________________________________________ __________________ Enroller Name (if known) – please print Date (mm/dd/yyyy)

Please Continue

32-90250-03 2011/01/11 (3/3)

Mail to: Security Financial Resources • PO Box 758549 • Topeka, KS 66675-8549 or Fax to: 1-785-438-4944

Visit us online at www.securitybenefit.com/Indiana • E-mail [email protected]

SECURITY BENEFIT PRIVACY POLICY

The privacy of Security Benefit’s customers is of utmost importance to us. You provide nonpublic personal information (“NPI”) to us in the course of doing business. We treat this information as confidential and restrict access to it.

We collect NPI about you from: (1) your requests for literature; (2) your applications and forms; (3) your financial advisor; and (4) your transactions with us. We do not sell information about current or former customers. We disclose information among our affiliates and to third parties as needed to process transactions or service your account. For example, we may contract with third parties to send you

statements. Also, we disclose information as required or permitted by law. Except with regard to California residents, we also may disclose information to companies: (1) that help us sell our products; and (2) with whom we jointly offer products. When we contract with others, we will require them to adhere to our privacy standards.

At Security Benefit, we restrict access to your NPI. Such information is given only to those who need it to provide products or services to you. We also maintain: (1) physical; (2) electronic; and (3) procedural safeguards to guard your NPI.

This Privacy Policy applies to the following companies: Security Benefit Life Insurance Company, Security Benefit Corporation, Security Distributors, Inc., First Security Benefit Life Insurance and Annuity Company of New York and Security Financial Resources, Inc. It also applies to UMB Bank, n.a., which is not related to Security Benefit Corporation, to the extent that UMB Bank, n.a. serves as Trustee of any Trust Account, Custodian of any Custodial Account, or provides other services to you.

®

38-10580-00 2009/11/13

Policy PROFESSIONAL STAFF

BOARD OF SCHOOL TRUSTEES 3122.01PLYMOUTH COMMUNITY SCHOOL CORPORATION

SUPPORT STAFF 4211.01

DRUG-FREE WORKPLACE

The School Board believes that quality education is not possible in an environment affected by drugs. It will seek, therefore, to establish and maintain an educational setting which is not tainted by the use or evidence of use of any controlled substance.

The Board shall not permit the manufacture, possession, use, distribution, or dispensing of any controlled substance, including alcohol, and any drug paraphernalia, by any member of the Corporation’s professional staff at any time while on Corporation property or while involved in any Corporation-related activity or event. Any staff member who violates this policy shall be subject to disciplinary action in accordance with Corporation guidelines and the terms of collective bargaining agreements.

The Superintendent shall establish guidelines that ensure compliance with this policy and that each staff member is given a copy of the standards regarding unlawful possession, use, or distribution of illicit drugs and alcohol by staff and informed that compliance with this requirement is mandatory. Such guidelines shall provide for appropriate disciplinary actions, if and when needed, which comply with the terms of any negotiated agreement.

41 USC 701 et seq., Drug-Free Workplace Act of 1988 20 U.S.C. 3224A

3122.01 F1/4122.01 F1

MEMORANDUM TO STAFF MEMBERS ON FEDERAL REGULATIONS CONCERNING DRUG PREVENTION

In accordance with Federal Law, the School Board prohibits the use, possession,

concealment, or distribution of drugs by employees on school grounds, in school or

school-approved vehicles, or at any school-related event. Drugs includes any alcoholic

beverage, anabolic steroid, dangerous controlled substance as defined by State statute, or

substance that could be considered a look-a-like controlled substance. Compliance with

this policy is mandatory for all staff members. Any part-time or full-time employee who

violates this policy will be subject to disciplinary action, in accordance with due process,

up to and including termination. When appropriate or required by law, the Corporation

will also notify law enforcement officials.

The Corporation is concerned about any staff member who is a victim of alcohol

or drug abuse and will facilitate the process by which s/he receives help through

programs and services available in the community. A staff member should contact his/her

supervisor or the Superintendent’s office whenever such help is needed.

_________________________________________ __________________

3122.01 F1/4122.01F2

CERTIFICATION REGARDING DRUG-FREE SCHOOLS

This is to certify that the Plymouth Community School Corporation has designed and

implemented the necessary policies and administrative guidelines to comply with the

requirements of Public Law 101 – (Drug Free Schools and Communities Act as amended

in 1989). The Corporation’s program shall:

1. emphasize the prevention of drug use;

2. provide standards of conduct that are applicable to all staff and which clearly prohibit, at a minimum, the unlawful possession, use, distribution of illicit drugs and alcohol on school premises or as part of any school activity;

3. include a clear statement that disciplinary sanctions, up to and including termination and referral for prosecution, will be imposed on staff members who violate the school standards of conduct and a description of those sanctions;

4. ensure that all staff members have been provided information about drug and alcohol counseling, rehabilitation, and re-entry programs available to them and how to make contact with an appropriate program;

5. ensure that all staff members have been given a copy of the standards of conduct regarding the unlawful possession, use or distribution of illicit drugs and alcohol by students and have been notified of the requirement that compliance wit the standards of conduct is mandatory.

A biennial review of the school corporation’s program will be conducted to determine its effectiveness, to implement changes as needed, and ensure that disciplinary sanctions are consistently enforced.

The Corporation has established an employee assistance program which includes guidelines for prevention, intervention, referral, treatment, and after-care.

The Corporation shall continue a good faith effort to maintain drug-free schools though compliance with the Drug-Free Schools and Communities Act.

Employee Date

PLYMOUTH COMMUNITY SCHOOL CORPORATION 611 Berkley Street

Plymouth, Indiana 46563

CERTIFIED EXPERIENCE RECORD AND SICK LEAVE BALANCE VERIFICATION

TEACHER NAME: _________________________________________________________________________

TO THE TEACHER: The Indiana State Board of Education has ruled that it is necessary for each teacher to have on file in the Office of the Superintendent, a certified record of all teacher experience, but not including substitute teaching. A year of experience has been defined as teaching on a regular contract for at least one hundred and twenty days per school year. This may be a public or private school, certified or commissioned by any State Department of Education in the United States. Place each year’s experience consecutively on a separate line, even if you taught several years in the same corporation. This form should be sent to the superintendent of each corporation for verification. When completed, the teacher should send the form to the Superintendent of Plymouth Community Schools.

TO THE SUPERINTENDENT: If the record given for this teacher while in your school system is correct, please sign and return. If not, make the corrections.

School Corp. Subject Taught School Year (dates)

Length of Term (days)

County Signature

Number of sick days remaining at last place of employment listed above: ______________________________________________

Sick days verified by: _______________________________________________ Title: ___________________________________

Payroll Deduction Authorization For

Annual LifePlex Membership (Effective September 1st of Each Year)

EMPLOYEE ONLY

EMPLOYEE & ONE HOUSEHOLD MEMBER

FAMILY

New Enrollees One Time Enrollment Fee Must Be Paid at LifePlex.

I hereby authorize Plymouth Community School Corp. to automatically deduct the appropriate amount per pay according to the plan I have selected above. Adjusting entries to correct errors are also authorized. This authority will remain in effect until Plymouth Community School Corp. has received approved cancellation from LifePlex in writing.

DEADLINE FOR FILING THIS FORM WITH PCSC CENTRAL OFFICE FOR NEW OR CHANGED MEMBERSHIPS IS:

Printed Name

Signature Date

common/payroll/Payroll Deduction Form for LifePlex 9-1-10.doc

Plymouth Community School Corp.

Current LifePlex Rates Effective 9-1-10

EMPLOYEE ONLY $450.00 Per Year

EMPLOYEE & ONE HOUSEHOLD MEMBER

$930.00 Per Year

FAMILY $1,170.00 Per Year

common/payroll/Payroll Deduction Form for LifePlex.doc

Elementary Teacher (K-6) Highly Qualified Verification

Section A - Teacher Information NAME: Last 4 Digits of SSN: Indiana Teacher License Number(s): Grade Level Assignment:

Years of Licensed Teaching Experience: Classroom Assignment: New Teacher Definition A new teacher is a teacher hired AFTER the 2006-2007 school year and/or has taught for one year or less while holding a valid teaching license. Veteran Teacher Definition A veteran teacher is a teacher hired PRIOR to or during the 2006-2007 school year for the current assignment and has more than one year of teaching experience while holding a valid license.

Section C - How will you become Highly Qualified? Check the boxes of the methods that you will complete to become Highly Qualified and answer the questions associated with your choice(s).

I will earn a bachelor’s degree from a regionally accredited institution. • By what date do you anticipate earning the degree? • From what institution of higher learning will you earn the degree?

I will earn a valid Indiana elementary school education teaching license.

• What type of license will you earn? • How many hours of credit do you need to complete your degree? • From which institution of higher learning will you eventually receive your degree? • What classes will you take towards your degree before the next school year?

Section B – Do you meet the definition of a highly qualified teacher? 1. Have you earned at least a bachelor’s degree? 2. Do you hold a valid Indiana elementary school education teaching license, includes Elementary

Primary (grades K-3) setting, Elementary Intermediate (grades 4-6) setting, or a special education teaching license that includes elementary school settings?

3. Have you completed at least one of the following: (Check the appropriate box if successfully completed)

Have you passed the PRAXIS II (#0011) licensing exam entitled “Elementary Education: Curriculum, Instruction and Assessment”

Have you passed the National Teacher Exam (NTE) (#0010) specialty test called “Education in the Elementary School”?

Have you been considered Highly Qualified in another state? Have you completed the National Board for Professional Teaching Standards (NBPTS)

certification in the Core Academic Subject area to which you are currently assigned? Have you earned 100 points on the HOUSSE rubric? HOUSSE is not an option for New

Teachers, and can only be used by Veteran Teachers hired prior to or during the 2006-2007 school year and who have not changed teaching assignments or school districts.

If you answered YES to ALL of the questions above, you meet the definition of Highly Qualified and do not need to complete the remainder of the form.

Documenting Teachers’ Highly Qualified Status for guidance on what items must be kept on file for HQ documentation.

Documentation of completion of each requirement MUST be kept on file at your central office. Please see

If you answered NO to ANY of the questions above, you DO NOT MEET the definition of Highly Qualified and should proceed to “Section C”.

• By what date will you have earned the license selected above? AND one of the following:

I will pass the PRAXIS II exam entitled “Elementary Education: Curriculum, Instruction and Assessment,” #10011

• List the date by which you are scheduled to take the exam • Name the site where you will take the test

I will earn National Board for Professional Teaching Standards (NBPTS) certification in my Core

Academic Subject area. • List the date that you are scheduled to take the certification.

I can demonstrate 100 points on the HOUSSE (High Objective Uniform State Standard of Evaluation)

rubric for elementary school teachers earned PRIOR to the end of the 2006-2007 school year (Note: HOUSSE is not an option for New Teachers nor for Veteran Teachers who have transferred or changed assignments since the 2006-2007 school year).

• List the date by which you will provide the Indiana HOUSSE and supporting documentation to your school corporation:

Make a copy of this form and ALL DOCUMENTATION for your records and send the completed information to your school corporation office. If you have any questions concerning this form, contact [email protected] HQTElementaryVerification-10.doc

http://www.doe.state.in.us/hqt/docs/INhousseRubricFeb3_FINAL.pdf�

mailto:[email protected]�

Secondary Teacher (7-12) Highly Qualified Verification

Section A - Teacher Information NAME: Last 4 Digits of SSN: Indiana Teacher License Number(s): Years of Licensed Teaching Experience:

Grade Level Assignment: Does your current teaching assignment include more than one Core Academic Subject? What Core Academic Subjects are you currently assigned to teach? (Check all subjects that apply.)

English reading / language arts mathematics science world languages social studies (civics and government, economics, history, geography) fine arts (music and visual

arts) (If you are assigned to teach more than one Core Academic Subject, you must meet all of the criteria below for each Core Academic Subject that you are currently assigned to teach.) New Teacher Definition A new teacher is a teacher hired after the 2006-2007 school year for the current assignment and/or has taught for one year or less while holding a valid teaching license. Veteran Teacher Definition A veteran teacher is a teacher hired PRIOR to or during the 2006-2007 school year for the current assignment and has more than one year of teaching experience while holding a valid license.

Section B – Do you meet the definition of a Highly Qualified Teacher? 1. Have you earned at least a bachelor’s degree? 2. Do you hold one of the following valid licenses for all Core Academic Subject areas that you are

currently assigned to teach? • Junior High/Middle School Teachers should hold a valid Indiana teaching license appropriate for

Junior High/Middle School (6-8), Secondary (grades 5-12), or a special education teaching license that includes middle school grades.

• High School Teachers should hold a valid Indiana secondary education teaching license or a special education teaching license (grades 9-12).

3. Have you successfully completed at least one of the following for EACH Core Academic Subject area that you are currently assigned to teach. Answer this question YES only if you have completed at least one of the following for every Core Academic Subject area that you are currently assigned to teach. If you are assigned to teach more than one Core Academic Subject and have completed one or more of the following but not for all of the Core Academic Subjects that you are assigned to teach, you must answer this question NO. (Check the appropriate box(es) if successfully completed.)

Have you passed the PRAXIS II in the core academic subject area to which you are currently assigned?

Have you passed the National Teacher Exam (NTE) specialty exam in the core academic subject area to which you are currently assigned?

Have you earned a bachelor’s degree or completed 24 college credit hours in the core academic subjects area to which you are currently assigned?

Have you earned a master’s degree in the core academic subject area to which you are currently assigned?

Have you completed the National Board for Professional Teaching Standards (NBPTS) certification in the core academic subject area to which you are currently assigned?

Have you been considered Highly Qualified in another state? For veteran teachers only, can you evidence 100 points earned on the HOUSSE rubric prior to

IF YOU ARE NOT HIGHLY QUALIFIED FOR YOUR CURRENT TEACHING ASSIGNMENT IN MULTIPLE CORE ACADEMIC SUBJECT AREAS, COPY AND COMPLETE THE FOLLOWING INFORMATION FOR EACH SUBJECT AREA FOR WHICH YOU ARE NOT HIGHLY QUALIFIED. Section C - How will you become Highly Qualified? Check the boxes of the methods that you will complete to become Highly Qualified and answer the questions associated with your choice(s). Based on the preceding information, for which Core Academic Subject area teaching assignments are you NOT considered Highly Qualified? (Check all subjects that apply.)

English reading / language arts mathematics science world languages social studies (civics and government, economics, history, geography) fine arts (music and visual

arts) CORE ACADEMIC SUBJECT AREA

I will earn a valid Indiana Core Academic Subject area teaching license. (Required for New and Veteran Teachers)

• In which Core Academic Subject area will you earn a license? • How many hours of credit do you need to earn your license? • From which institution of higher learning will you eventually receive your degree? • What classes will you take towards your degree by next school year? • By what date will you have earned the license selected above?

AND one of the following:

I will pass the PRAXIS II exam in my Core Academic Subject area. • List the date that you are scheduled to take the exam. • Name the site where you will take the test.

I will earn a bachelor’s degree or complete a minimum of 24 college credit hours in my Core Academic

Subject area. • If completing credit hours, how many additional hours do you need to earn in the Core Academic Subject

area? • How many hours will you complete by next school year? • By what date do you anticipate having the full 24 college credit hours required? • If earning a degree in the Core academic Subject, how many college credit hours do you have left to

earn? • From which institution of higher learning will you eventually receive your bachelor’s degree? • By what date do you anticipate earning the bachelor’s degree?

the end of the 2006-2007 school year? Note: HOUSSE is not an option for New Teachers or for teachers who have transferred or changed assignments since the 2006-2007 school year.

If you answered YES to ALL of the questions above, you meet the definition of Highly Qualified and do not need to complete the remainder of the form.

Documenting Teachers’ Highly Qualified Status for guidance on what items must be kept on file for HQ documentation.

Documentation of completion of each requirement must be kept on file at your central office. Please see

If you answered NO to ANY of the questions above, you DO NOT meet the definition of Highly Qualified and need to proceed to “Section C”.

I will earn a master’s degree in my Core academic Subject area. • How many hours of credit do you need to complete your master’s degree? • From which institution of higher learning will you eventually receive your master’s degree? • How many hours will you complete by next school year? • By what date do you anticipate earning the master’s degree?

I will earn National Board for Professional Teaching Standards (NBPTS) certification in my Core

Academic Subject area. • List the date that you are scheduled to earn the certification.

I can demonstrate 100 points on the HOUSSE (High Objective Uniform State Standard of Evaluation)

rubric for the Core Academic Subject earned by the end of the 2006-2007 school year. Note: Only veteran secondary teachers hired prior to or during the 2006-2007 school year and who have not changed assignments may use the HOUSSE rubric to demonstrate meeting the Highly Qualified Teacher standards. List the date by which you expect to present the Indiana HOUSSE rubric and all supporting documentation to your school corporation: Make a copy for your records and send the completed information to your school corporation office. If you have any questions concerning this form, contact [email protected] HQTSecondaryVerification-10.doc

http://www.doe.state.in.us/hqt/docs/INhousseRubricFeb3_FINAL.pdf�

mailto:[email protected]�

3430F1


PERSONAL LEAVE

I hereby request that my absence from assigned duties occurring on

and amounting to day(s) be taken from my leave.

The reason and necessity for my absence is described as follows:

Date Teacher

Date Principal

Request acknowledged: Superintendent

Request not approved for reason stated:

Date Superintendent

New Form 6/27/11

PRESCRIBED BY STATE BOARD OF ACCOUNTS GENERAL FORM NO. 101 (1955)

TO

ON ACCOUNT OF APPROPRIATION NO FOR

FROM AUTOMILES

MILEAGEPER MILE

YR 2011 POINT TRAVELED

AUTO LICENSE NO.

+ ODOMETER READING columns are to be used only when distance between points cannot be determined by fixed mileage or official highway map.

Date Signature

POINT

MILEAGE CLAIM

ODOMETERREADING +

DATE

START FINISHNATURE OF BUSINESS

TO

(GOVERNMENTAL UNIT)

(OFFICE, BOARD, DEPARTMENT OR INSTITUTION)

Pursuant to the provisions and penalties of Chapter 155, Acts 1953, I hereby certify that the foregoing account is just and correct, that the amount claimed is legally due, after allowing all just credits, and that no part of the same has been paid.

TOTALS

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

Prescribed by State Board of Accounts State Form No. 523 (Rev. 1995)

An invoice or bill to be properly itemized must show:kind of service, where performed, dates service renderd,by whom,rates per day, number of hours, rates per hour, number of units, price per unit, etc.

Purchase Order No.

Terms

Date Due

Total

I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and that the materials or servicesitemized thereon for which charge is made were ordered and received except

Mo. Day Yr.

I hereby certify that the attached invoice(s), or bill(s), is (are) true and correct and I have audited same inaccordance with IC 5-11-10-1.6.

Mo. Day Yr. Treasurer

InvoiceDate

InvoiceNumber

Description(or note attached invoice(s) or bill(s) Amount

TitleSignature

ACCOUNTS PAYABLE VOUCHERPLYMOUTH COMMUNITY SCHOOL CORPORATION - 611 BERKLEY ST. - PLYMOUTH, INDIANA 46563

Payee

SAMPLE

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SAMPLE

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SAMPLE

EMPLOYEE DEDUCTIONS

Name Date of Hire

Code Amount Tp Description Limit

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

SAMPLE

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