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MSD 426-A REV: 2020 Report all personnel changes on this form Send TWO COPIES prior to payroll affected by this change. SUPPLEMENTARY PAYROLL CERTIFICATION AND REPORT OF PERSONNEL CHANGE Month Day DATE Year To: Cortland County Personnel/Civil Service From: (City/County/Town/Village or School/Housing Authority/ Soil & Water) (Name only one) Department Positon Number of last employee NAME AND TITLE OF LAST EMPLOYEE IN POSITION (USE ONLY FOR REPLACEMENT) IF NEW POSITION, NOTE BELOW New position number: Name of Employee Address C.S. Title of Position Salary/hourly rate Grade Step ☐ Veteran ☐ Disabled Veteran ☐ Non-Veteran ☐ Exempt Volunteer Fireman Date of Birth Social Security Number Retirement Reg. Number Check Nature of Personnel Change Date Effective / Probation Action Necessary by Appointing Officer APPOINTMENT Permanent Competitive Probation: Return Certificate of Eligibles Contingent Permanent (Competitive Only) Probation: Return Certificate of Eligibles Permanent Promotion (Competitive Only) Probation: Return Certificate of Eligibles NCP (Competitive only) Probation: Return Certificate of Eligibles Provisional (Competitive only) Attach application Provisional Promotion (Competitive Only) Attach application Permanent Non-Competitive Class Attach application Permanent Labor Class Attach application For Term of Office Elected☐ Exempt ☐ Unclassified ☐ From To Give facts under “Remarks” Temporary From To State length of employment; attach application or “Certification of Eligibles”. Reinstated Date: Give facts under “Remarks” Part Time ☐ Competitive ☐ Non-Competitive ☐ Labor Class # of hours per week Give facts under “Remarks”; attach application, I-9, W- 4, Retirement Option and Hiring Freeze Authorization TERMINATION Resignation Date: Submit signed resignation and exit interview Retirement Date: Give effective date/ attach letter/ exit interview Deceased Date: Give effective date Removal Date: Attach copy of proceedings Lay-off (Lack of Work or Funds) Date: Give facts under Remarks Other Terminations Give facts under Remarks OTHER CHANGES Leave of Absence ☐ paid ☐ Unpaid OR ☐ FMLA: ☐ Paid ☐ Unpaid ☐ Military: ☐ Paid ☐ Unpaid From To Give facts and type of leave under ”Remarks”; attach unpaid leave request/ attach Military Orders Worker’s Compensation ☐ 207C ☐ Paid ☐ Unpaid ☐ Give facts under “Remarks” Return from Leave of Absence Worker’s Comp ☐ 207C ☐ FMLA ☐ Give facts under “Remarks” Transfer Give reason under Remarks Passed Probation Effective Date Give reason under Remarks Reassignment Give reason under Remarks Demotion ☐ Suspension ☐ Give reason under Remarks Change in Classification Effective Date Give date of Civil Service classification action New Position Submit Resolution Change in Salary Raise ☐ Longevity ☐ Indicate new salary $ Change in Name ☐ Address ☐ Phone ☐ Give facts under Remarks Other changes: Give facts under Remarks REMARKS: (Continue on back if necessary): Signature, Appointing Officer: Title Address CERTIFICATE valid until (Date) This certifies that the above employment is in accordance with Law and Rules made in pursuance to Law. Subject to any limitation or condition specified above. By: Date: