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Employee Information Forms

If you are in need of specific forms and information, please click on one of the following links that matches your needs and print any available forms there.

• Vacation/Personal Time Donation Forms and Information

Employee Forms

Print out needed forms and inter-office mail to Human Resources when completed

• Employee Change Notice Form

• Name Change

• Address Change

• Phone Number's Change

• Emergency Contact Change

• Auto Deposit

• Federal Withholding Form.2012

• Payroll Deductions Cancellation Form

• State Withholding Form.2012

• Application for Leave of Absence (Benefit Continuation Form)

Benefit Forms

The Department of Human Resources is responsible for maintaining the forms for the administration of the benefits offered to County employees and their families.  To find a form click on the links below:  All forms must be signed before changes can be made to the employee benefits. 

Dental

• Add/Cancel Dependents

Health

• Add/Cancel Dependents

• Primary Care Physician Designation/Change

• Wellmark Benefit Summary

Vision

• Add/Cancel Dependents

EMC Life

• Enrollment

• Change Coverage

• Beneficiary Change

• Evidence of Insurability

Principal GUL

• Change Coverage

• Beneficiary/Name Change

• Cancel Insurance

• Adjustment Application

Deferred Compensation

Please print, complete, and inter-office all files to Lola Evans at Human Resources.  For questions or information regarding Deferred Compensation, please call the Human Resources department at (515) 286-3200.

• Change Form

• Hardship Withdrawal

IPERS

• Address/Name Change

• Enrollment/Beneficiary Form

Members frequently request the forms listed below. Each form opens in a pdf format, which is good for viewing and printing, although you must have Adobe Reader installed on your computer. Some forms have an online version that you can fill in from your computer and submit electronically.

• http://www.ipers.org/members/forms/index.html

Flexible Spending

• Enrollment Form

• Reimbursement Form

• Direct Deposit Authorization Form

• Flex Dollar Form (Mgmt/Supervisor/Excluded Only)

Parking Program

• Enrollment/Change Form

• Parking Reimbursement Form

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Please feel free to contact us with questions or comments at humanres@polkcountyiowa.gov