INSTRUCTIONS FOR COMPLETING END OF YEAR EXIT PAPERWORK
** DO NOT PRINT DOUBLE SIDED ** USE BLUE OR BLACK INK ONLY
1. EMPLOYEE PAYOFF AND BENEFIT ELECTION FORM• Please read all instructions and choose the appropriate option.• NOTE: For additional questions on this form please contact RISK
MANAGEMENT at 281.396.2241.
2. EXIT REPORT FORM• Complete TOP PORTION ONLY. (An accurate mailing and email address
is imperative.)
3. CHANGE OF ADDRESS, PHONE NUMBER, STATUS FORM• This form is to be COMPLETED ONLY if there are changes to your
address, phone number or status upon exit with Katy ISD. Otherwise, youmay disregard this document.
Documents should be returned to Human Resources by one of the following ways: • Email to [email protected]• In person at the Education Support Complex Annex• Interoffice mail to Human Resources Department• By mail to 438 FM 1463 Katy, TX 77494
For additional assistance with the exit process, you may contact:
• PROFESSIONALSo Tracey Sherrill – 281.396.2351 or [email protected]
• PARAPROFESSIONALS & AUXILIARYo Ana Reyes – 281.396.2374 or [email protected]
HUMAN RESOURCES DEPARTMENT EMPLOYEE PAYOFF AND BENEFIT ELECTION FORM FOR EMPLOYEES WHO WORK 226 DAYS OR LESS
House Bill 973 entitles school district employees to continue benefits through the summer months of a given
school year if they resign or retire effective after the last day of instruction. Katy ISD is in compliance with that
legislation and will continue elected benefits for all employees according to their choice.
Retiring or resigning employees who work 226 days or less per year but are paid on a 12‐month basis may
request an early payoff. Katy ISD can grant your request but the district needs to verify your requested payoff
date and how your benefits are to be handled.
Please choose the date of your final paycheck and when you want to end your benefits in the boxes below
___________________________ ________________ ____________________ Printed Employee Name Employee Number Date
___________________________ ________________________ Employee Signature Position/Title
If you have questions regarding HB 973, you may call the KISD Risk Management Department at 281‐396‐2241.
Option 1
______ NO early payout. Your final paycheck will be August 15th and your benefits will end August 31st
OR
Option 2
______Receive final paycheck on June 30th. (If you want to extend your benefits beyond June 30th, all premiums will be deducted from your final paycheck.)
If you choose Option 2, you must also choose one of the following.
______I choose to end my benefits on June 30th
______I choose to end my benefits on July 31st
______I choose to end my benefits on August 31st
��������������� ����������������������������� !�"�����#$%&��!�'(�($ �)*+,-./.�0123�45�)67189:�7;9�199<9<=�>?@ABCD�EF�@GEDH?�CI�EJJK?>>�EDJLCK�MGCD?�DNOP?K�QRSTUS�VUS�WXYZU�[\]R_SS�SRabScdZeS�f�VghTfS�iVc�gScUjTR�Zjkc\TfZjl�mnop�q�rst�us�vwx�yz{|�z}}|~~��s��t��~�����sr||��|��|�{�}|����|z~|�}s���|�|��|}��s����z�u��s��z�u��s��t�z���|~st�}|~��s����s}|~~���������������� ������������ ���� �¡¢��¢£�� ¤��¥¦�§¢�¥©�ª«¬�«®����°±�²³«®�£���µ�°µ�²¶«®��£����°±���·�¹�º»»�������¼�°µ���½®¹�º»»������¾¿ÀÁÂÃÄÄ�ÅÆÇÈÉÊËÌÄÍ� ÎÉÏÄÍ�>?@ABCD�PF�@GEDH?�CI�>AEAN>� ÐÑQRSTUS�VUS�WVjZU�[\]R_SS�SRaÒScdZeS�f�VghTfS�iVc�gScUjTR�Zjkc\TfZjÓ�mnop�q�rst�us�nmx�yz{|�z}}|~~��s��t��~�����sr||��|��|�{�}|����|z~|�}s���|�|��|}��s��Ôz�u��s��z�u��s��t�z���|~st�}|~��s��Õ�s}|~~��Ö×�ª��������� ������������ ���� �¡¢��¢£�� ¤��¥¦�§¢�¥Ø�ª«¬��«®���°±�¡���Ù��� Ú�ÛÜÝÞßà� Ú�áâããÜàä� Ú�åÜæçãèàä� Ú�éÜäçêàä�¾¿ÀëÂÃÄÄ�ÅÆÇÈÉÏìíÄÍ� ÎÉÏÄÍ�îïðñò� îóôõ�ö÷ó��õ��ô�����õ�ôó�õ��������÷õ�÷ó��õ���� ó���îóôõ�������õ���ô��������������õ��õ��ó�õ��
Katy Independent School District
Human Resources Department
Exit Packet - Service Record Request Form (Please print clearly)
Employee Name: _______________________ Campus/Department:___________ KISD Employment Date(s): ______________________
Request Date: _______________ Resign Date: __________________
DOB: _______________ Last 4 SS #: __________________
Contact Phone #: ______________ Email address: __________________
*If you are resigning after the current school year completes, your record will be available approx. mid-July to late August depending on the volume of request.
*If you are resigning mid-year, your record will be available after your last pay check with the district.
Employee: (Official Record) Mailing Address:
_________________________________________
_________________________________________
_________________________________________
New School District: (Scanned to HR Contact) New School District Name: __________________________________ New District HR Contact: __________________________________ New District HR Email Address: __________________________________
Employee Signature: _____________________________________
Service Record Contact: 438 FM 1463 Katy, TX 77494 Phone #: 281-396-2347 [email protected]
������������
�������� � !"#������ � $"%%& ���� �
$�"&"'(�)%%# ���*# +,#%��-"&&�. ���"& %��,��/"���%%# ��0� 1"�2� 3��� � 4"5�
6/,' 7� 8�5&,2 �9:�7� 6 #�,'�&�8;��"&�)%%# ���*5�2�"'<,=�-"&&�. �� '���,��/"�� ��"&0��
>,.�?"�& � �,+��",@A1��5B�� �����:�2�,<�C,#D�
E ��,'�F#�G �H"'(�
8�5&,2 �3"('��B# � �����I�%"("���,J�3,+"�&�3 +B#"�2�7�
KKKLKKL
MMNO�PQR�STUV�TWXYQZT[�\Q]]VZX�Q_�\QZ\V_Z�XSTX�PQR�YS�XQ�aY\R b�c[VTV�\SV\d�SV_Ve�f�g�_Vh_VVZXTXYUV�O_Q]�iR]TZ�jVQR_\V�Yk�\QZXT\X�PQR�T�QQZ�T�lQ mn[Vo�
E ��,'�q�#�� #�"'��",'��w�8�5s,2 �H,&B'��#"s2�# �"(' %ApB"��u�8�5s,2 �&�"%�,q��%B ��,�&�+D�,<�-,#D���8�5s,2 �-���%"��"�� %�F#��"�+,'%B+��,#�,�/ #�(,,%�+�B� �w���/ #��
9�� �5&,2 � s"(".s �q�#�# /"# t� ��v �� ��v ��������E �"# � u�,�
9<�� 5�#��",'�-���H,&B'��#2��-����% pB�� �',�"+ �("H 't� w�v �� u�,�
��������������������� ¡���¢�����£¤¥ $ �/,%����6/,' �1�&&���¦§§©ª«� :�� ��¬��������
x<� �5&,2 �-���%"��"�� %�F#��"�+,'%B+��,#�,�/ #�(,,%�+�B� �� ®5&�"'��
B��'�E �,B#+ ��: 5�#�� '��E 5# � '���"H �3"('��B# � :�� �
Employee Section
Human Resources Section