W-4 Form
Employee Withholding Allowance Certificate

This is the IRS W-4 form. Employees use this form to make changes to their payroll tax exemptions. If you want different amounts deducted for your federal and state income taxes, fill out a separate form for each and note at the top "FEDERAL" or "STATE". For additional information, contact your personal tax advisor. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

W-5 Form
Employee Earned Income Credit Form

This is the IRS W-5 form. The instructions will tell you if you qualify for the Earned Income Credit (EIC). For additional information, contact your personal tax advisor. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

W-2
Reissue request Form

This is the IRS W-2 Reissue request form.

Payroll
Advance Form

This is the State of Oregon Payroll Advance form. Eligible employees may qualify for an emergency payroll advance of 60% of wages earned to date, less any court-mandated deductions. Once filled out, give this form to your supervisor for approval. Your supervisor will send this form to your DHS Payroll contact for approval and to process the payroll advance request. There is a 24-48 hour turnaround to receive the payroll advance if approved.

Work Schedule
Request

DHS form to request a change of work hours schedule.

Payroll
Direct Deposit
Form

This is the State of Oregon Payroll Direct Deposit form. Employees may have up to 4 fixed deposits (specific dollar amounts) and 1 net deposit (balance of your net check). Virtually all banks and credit unions participate in Direct Deposit. Check with your co-workers... you'll find that 72% of State of Oregon employees participate in Direct Deposit. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

Governor's Food Drive
Food Bank Deduction Form

Help those in your community less fortunate than you. You can support your local food bank by payroll deduction. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

Social Security Card
Request Form

This is the Social Security Card Request form. Use this form to apply for a social security card, or to request a copy of your social security card. This form must be taken in to your local Social Security Office with the necessary documentation to complete your request.

Employee Emergency Information Form

This is the Employee Emergency Information form. Use this form to change your emergency contact information. Once filled out, please send this form to your Human Resources contact as soon as possible.

Employee Leave Request Form DHS 46

This is the Employee Leave Request form. You can fill this form out online then print and sign it. Once filled out, send this form to your supervisor as soon as possible for approval.

Early Check Release Form

Used when an employee will be unavailable on a normal payday and is picking up his or her check prior to the check date.

Hardship Leave Transfer Authorization Form DHS2110

Used to donate vacation leave hours to other employees.

Understanding
Your State of Oregon
Paycheck

This information will help you better understand your State of Oregon Paycheck or Direct Deposit Stub.

PEBB
Medical Enrollment Form

This is the PEBB Medical Enrollment form. This form is used at Open Enrollment to sign up for medical benefits. This form is also used by new employees to sign up for medical benefits. New employees have 60 days to complete this form. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

PEBB
Dental Enrollment Form

This is the PEBB Dental Enrollment form. This form is used at Open Enrollment to sign up for dental benefits. This form is also used by new employees to sign up for dental benefits. New employees have 60 days to complete this form. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

PEBB
Medical/Dental Update Form

This is the PEBB Medical/Dental Update form. This form is used during the plan year to make changes to your medical and dental benefits due to a qualified family status change. A qualified family status may include marriage, divorce, birth, death, and changes in your work status or the work status of your spouse/domestic partner. You have 31 days from the date of the qualifying family status change event to complete this form. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

PEBB
Dependent Care Form

This is the PEBB Dependent Care form. This form is used at Open Enrollment to sign up for the PEBB Dependent Care Account. This form is also used by new employees to sign up for the PEBB Dependent Care Account. New employees have 60 days to complete this form. Once filled out, please send this form to your DHS Payroll contact as soon as possible.

PEBB
Dependent Care Update Form

This is the PEBB Dependent Care Update form. This form is used during the plan year to make changes to your PEBB Dependent Care Account due to a qualified family status change. A qualified family status may include marriage, divorce, birth, death, and changes in your work status or the work status of your spouse/domestic partner. You have 31 days from the date of the qualifying family status change event to complete this form. Once filled out, please send this form to your DHS Payroll Contact as soon as possible. This information will be submitted to PEBB for approval.

PEBB
Life Insurance Enrollment Form

This is the PEBB Life Insurance Enrollment form. This form is used at Open Enrollment to sign up for employee life insurance, spouse/domestic partner life insurance, disability insurance, and dependent life insurance. This form is also used by new employees to sign up for employee life insurance, spouse/domestic partner life insurance, disability insurance, and dependent life insurance. New employees have 60 days to complete this form. Once filled out, please send this form to your DHS Payroll contact as soon as possible.

PEBB
Life/Disability Update Form

This is the PEBB Life/Disability update form.

PEBB
Domestic Partnership
Affidavit Form

This is the PEBB Domestic Partner Affidavit form which must be filled out to enroll an employee's domestic partner for insurance benefits. Once filled out, please send this form to your DHS Payroll contact as soon as possible.

PEBB
Domestic Partnership
Termination Form

This is the PEBB Domestic Partner Termination form which must be filled out to end a domestic partnership for insurance benefits. Once filled out, please send this form to your DHS Payroll Contact as soon as possible.

PERS
Variable Enrollment Form

This is the PERS Variable form. This form is used by PERS-eligible employees to move 25%, 50%, or 75% of their PERS account into the PERS Variable Account. This is an important financial decision, so please contact your PERS Employee Counselor before making this decision. This form may be filled out at any time during the year, however, the change takes effect the following January 1 after PERS has received the form. Once filled out, please send this form to your DHS Payroll contact as soon as possible.

PERS
Designation of
Beneficiary Form

This is the PERS Beneficiary form. This form is used by PERS-eligible employees to provide beneficiary information to PERS. This is a two-section form... one section is the "standard" beneficiary statement, and the other section allows the employee to specifically designate who their beneficiary is. PLEASE NOTE: fill out either Section B or Section C only. Once filled out, please send this form to your DHS Payroll contact as soon as possible.

Standard Insurance
Short Term Disability Policy

This is the Standard Insurance Company Short Term Disability policy, which can answer questions regarding your short term disability insurance.

Standard Insurance
Long Term Disability Policy

This is the Standard Insurance Company Long Term Disability policy, which can answer questions regarding your long term disability insurance.

Standard Insurance
Group Life Insurance Policy

This is the Standard Insurance Company Group Life Insurance policy, which can answer questions regarding your optional employee, spouse, domestic partner, and/or dependent life insurance.

Standard Insurance
Accidental Death and Dismemberment Policy

This is the Standard Insurance Company Accidental Death and Dismemberment policy, which can answer questions regarding your accidental death and dismemberment insurance.