Forms
All forms are PDF and open in a new window unless otherwise indicated.
New Employee Packet (Part-Time without Benefits)
Benefit Forms
- Basic Life Insurance Enrollment Form
- Flexible Spending Election Form - pdf
- Flexible Spending Request for Health Care Reimbursement Form (UMR) pdf
- Flexible Spending Request for Health Care Reimbursement Form (UMR) word
- Flexible Spending Request for Dependent Care Reimbursement Form (UMR) pdf
- Flexible Spending Request for Dependent Care Reimbursement Form (UMR) word
- Express-Scripts Prescription (Retail) Reimbursement Form
- Express-Scripts Prescription (Home Delivery) - obtain forms in the Office of HR
- Health/Dental Enrollment/Change Form
- Health and Dental Claim Form
- Health/Dental Adult Child Affirmation
- Long-Term Disability Enrollment Form
- Optional Life Insurance Enrollment Form
- Optional Personal Accident Insurance Enrollment Form
- Cigna Life Beneficiary Change Form
- Retirement Plan Contribution Form
- Retirement Plan Beneficiary Change Form
- Retirement Annuity Enrollment Form
- Retirement Annuity Enrollment Form (for use by Collective Bargaining Employees)
- Group Supplemental Retirement Annuity Enrollment Form
- Emeriti Voluntary Salary Deduction Agreement
- Emeriti Qualified Medical Expense Reimbursement Form
Forms Used in the Hiring Process
- Temporary Employees Employ/Term
- Top Ten Report (formerly Hiring Report II)
- Final Hiring Report (formerly Hiring Report III)
- Employee Information Form
- Housing Information Form
- Moving Relocation Policy
- Moving Expense Reimbursement Form
- Direct Deposit Authorization Form
- Receipt of Handbook Form
- I-9 Form
- W4 form
- IT-4
- City of Mount Vernon Tax Form
- Background Check Authorization Form
- Acknowledgment Form; Receipt of Notices and Other Disclosures via Electronic Media
- Universal Availability Notice
FMLA Forms
- Certification of Health Care Provider for Employee's Serious Health Condition
- Certification of Health Care Provider for Family Member's Serious Health Condition
- Notice of Eligibility and Rights & Responsibilities
- Leave Designation Notice
- Certification of Qualification Exigency for Military Family Leave
- Certification for Serious Injury or Illness of Covered Servicemember-for Military Family Leave
Employee Rights and Responsibilities Under the Family and Medical Leave Act
Department of Labor FMLA website
Other Forms
- Injury Reporting Kit
- Evaluation Form -- Administrators- (Traditional) pdf
- Evaluation Form - Administrators - (Traditional) word
- Evaluation Form - Administrators - (AI, Alternative) pdf
- Evaluation Form - Administrators - (AI, Alternative) word
- Evaluation Form -- Nonexempt Staff- pdf
- Evaluation Form - Nonexempt Staff - word
- Pre-Evaluation Form -- Nonexempt Staff
- Report of Work-Related Incident/Injury
- Position Description Questionnaire Non Exempt Staff-pdf
- Postion Description Questionnaire Non Exempt Staff - word
- Domestic Partner Information and Certification
- Domestic Partner Termination Form
- Travel Expense Form