HUMAN RESOURCES Katherine Gardner, Director · _____ Transcripts stating conferred date of Bachelors degree or Alaska Teaching Certificate (to receive the higher rate of pay). Note:

HUMAN RESOURCES Katherine Gardner, Director

Mission: Mat-Su Borough School District prepares students for success

501 N. Gulkana Palmer, Alaska 99645-6147 Ph: 907.746.9245 Fax: 907.761.4088 www.matsuk12.us

SUBSTITUTE APPLICATION CHECKLIST

PLEASE NOTE: Applicant must be a high school graduate or have completed his/her GED to qualify for a substitute position with the District. The District reserves the right to request supporting documentation indicating this status. All substitutes are “at will”, on call, temporary employees, and are not guaranteed any work. This publication is not intended to form an agreement or contract of any kind between Matanuska-Susitna Borough School District and its substitute employees. This application in no way alters the “at will” employment of substitute employees. Please check to see that you have completed all of the following required items before returning to the Human Resources Department.

REQUIRED INFORMATION _____ Completed Application _____ Substitute Action Form

_____ State of Alaska Supplemental Annuity Plan Beneficiary Designation _____ Form SSA-1945 (Not Covered by Social Security Form)

_____ I-9 Form. Have acceptable identification available; see I-9 form for list. (Example: driver’s license AND social security card). _____ W-4 Form

_____ Direct Deposit Form

_____ Substitute Interview Form; must have completed an interview with appropriate District Administrator based on subbing area prior to submission of application. To arrange, call 746-9200.

_____ High School Diploma or other documentation to verify completion of High School or equivalent program. Transcripts stating conferred date of an Associate degree or above will satisfy this requirement.

_____ Electronic Information Resource Contract (entire document available upon submission of application) _____ Terms of Employment & Receipt of Policy Form (to be signed upon submission of application)

_____ MSBSD Test Security Agreement _____ Interested Person Report from Alaska State Troopers located at: 453 South Valley Way, Palmer, AK 99645 Hours: Monday - Friday 8:00 AM – 4:30 PM To obtain you will need: Alaska Drivers License or Alaska ID Card and $20.00 processing fee (cash or check only, payable to the State of Alaska). _____ Fingerprinting Form; a list of recommended fingerprinting service providers is enclosed in the application. Incomplete applications will not be accepted. If a fingerprint appointment is scheduled

with the MSBSD, then all required forms must be completed prior to being fingerprinted. Fingerprints taken with the MSBSD are $70. We accept cash or check only, payable to MSBSD. If paying with cash, exact change is appreciated.

OPTIONAL INFORMATION _____ Transcripts stating conferred date of Bachelors degree or Alaska Teaching Certificate (to receive the higher rate of pay). Note: Diplomas are not acceptable. We prefer official transcripts, however we will accept unofficial transcripts if they are in a comprehensive format provided by the university/college and contain all information

necessary for determining that a Bachelor’s degree has been conferred.

_____ Certificate of Substitute Diploma _____ Equal Employment Opportunity Survey _____ 403 B Tax Shelter Annuity Election Form (Only available if you have a current account

Additional information for subbing in specialized areas: _____Copy of Alaska Teacher Certificate (long term sub for certified teachers only). _____Copy of commercial driver’s license and current driving record (drivers only). _____Contact made with Nutrition Services 861-5100 (food service only). _____Interview with Health Services and copy of RN license (nurses only). _____Interview with a supervisor of Operations and maintenance for Custodial Subs.

HUMAN RESOURCES DEPARTMENT


501 N. Gulkana Palmer, Alaska 99645-6147 Ph: 907.746.9245 Fax: 907.761.4088

www.matsuk12.us

MEMORANDUM

TO: ALL MSBSD SUBSTITUTES FROM: MSBSD HUMAN RESOURCES DEPARTMENT DATE: JANUARY 13, 2014 SUBJECT: NEW REQUIREMENT FOR SUBSTITUTE POSITIONS: ORIENTATION & TRAINING Substitute applicants hired after December 31, 2013 are required to attend an orientation & training session. This requirement must be fulfilled within sixty (60) days from the date the substitute application is processed through the Human Resources Department. Failure to complete this requirement in the sixty (60) day timeframe will result in removal from the active substitute list until the substitute attends the mandatory orientation and training. Substitute Orientation (45 minutes)

District Policies & Regulations District Systems (Aesop, Outlook, Munis Employee Self-Service) Payroll & School Information Training Resources

Substitute Hire Training (3 hours) *

District Programs Classroom Management Protocol & Expectations

*This training is not required for substitutes signing up exclusively for food service and/or custodial positions. Food service and custodial substitutes who sign up for additional positions after their initial application is processed will be required to attend this training within sixty (60) days from the date they submit the request to add the additional positions. Current Available Dates:

January 21, 2014 (Tuesday) February 18, 2014 (Tuesday) March 18, 2014 (Tuesday) April 15, 2014 (Tuesday)

Time: 8:00 AM – 12:00 PM Substitute Orientation: 8:00 AM – 8:45 AM Substitute Hire Training: 9:00 AM – 12:00 PM Location: MSBSD Administration Building 501 N. Gulkana St. Palmer, AK 99645 Sign-up by accessing the following web link: www.matsuk12.us/subtraining

http://www.matsuk12.us/subtraining

MAT-SU BOROUGH SCHOOL DISTRICT SCHOOL TELEPHONE LIST SCHOOL PHONE # ADMINISTRATOR

PRINCIPAL/TEACHER

American Charter Academy Burchell High School Colony High School Houston High School Mat-Su Career & Tech. Mat-Su Day School Palmer High School Su Valley Jr/Sr High Valley Pathways Wasilla High School Colony Middle School Houston Middle School Palmer Middle School Teeland Middle School Wasilla Middle School Academy Charter Big Lake Elementary Birchtree Charter School Butte Elementary Cottonwood Creek Elem. Finger Lake Elementary Fronteras Charter Glacier View K-12 Goose Bay Elementary Iditarod Elementary Knik Elementary Larson Elementary Machetanz Elementary Meadow Lakes Elementary Mat-Su Central School Midnight Sun Charter Pioneer Peak Elementary Shaw Elementary Sherrod Elementary Snowshoe Elementary Sutton Elementary Swanson Elementary Talkeetna Elementary Tanaina Elementary Trapper Creek Elementary Twindly Bridge Charter Willow Elementary

352-0150 864-2600 861-5500 892-9400 352-0400 864-2040 746-8400 733-9300 761-4650 352-8200

761-1500 892-9500 761-4300 352-7500 352-5300

746-2358 892-9700 745-1831 861-5200 864-2100 864-2200 745-2223 861-5650 352-6400 352-9100 352-0300 352-2300 864-2300 352-6100 352-7450 357-6786 861-5700 352-0500 761-4100 352-9500 861-5600 861-5300 733-9400 352-9400 733-9450 376-6680 495-9300

Becky Huggins Adam Mokelke Cydney Duffin Bill Johnson Mark Okeson Wolfgang Winter Reese Everett Jason Mabry Jim Wanser Amy Spargo Mary McMahon Benjamin Howard Tom Lytle Katie Ellsworth Leigh Stanton Barbara Gerard John Simon Catherine Busbey Dan Kitchin Lisa Vrvilo Dave Nufer Jennifer Schmidt Wendy Taylor Brooke Kelly Scott Nelson Traci Pedersen Sheela Grennan-Hull Jennifer Dowd Carl Chamblee John Brown John Weetman Dan Molina Dave Russell Dan Michael Carol Boatman Joshua Rockey Mary Kate Mayer Carol Wadman Jim Simmons Allison Wall Gerald Finkler Andrew McDermott

To: Substitute Applicants From: Human Resources Department Date: July 1, 2013 Re: Instructions for Substitute Applicants Thank you for applying as a substitute for the Mat-Su Borough School District. The following is a summary of the requirements for becoming a substitute employee for the Matanuska Susitna Borough School District. This memo is intended as a guide to help you avoid delays in being established as a substitute employee. 1. Please read all material carefully and return all forms with your application, whether

you think they are relevant or not. Please allow 2 to 3 business days for the processing of all complete applications. Incomplete applications will not be accepted.

2. All substitutes are “at will”, on call, temporary employees, and can be dismissed at any

time for any reason deemed appropriate by the District. You will be on the active substitute list for this entire school year, (July 1 to June 30). You have reasonable assurance of being called on any regular workday. Holidays, vacation days, and summer vacation are just like a weekend and you will not be called to work those days. During the summer, in order to update our records, you may be asked to verify your interest in continuing to substitute.

3. All new employees must be fingerprinted (AS 12.62.160). The Human Resources

Department is now scheduling morning appointments for those individuals who prefer not to drive to Wasilla or Anchorage. Enclosed is a list of fingerprinting service providers along with the cost for the service. Fingerprinting will need to be completed prior to turning in your substitute application. Appointments can be made at 907-746-9200. Inside is the form that needs to be signed by the fingerprinting official confirming that fingerprints have been taken and are being processed. In addition to fingerprints an “Interested Persons Report” needs to accompany this application.

4. Please be sure that you have the proper identification (i.e., driver’s license AND social

security card) required by the Immigration Naturalization Service. You will find the list of acceptable identification on the reverse side of the I-9 form in your packet. NO exceptions can be made to these requirements.

5. Substitute applicants must go through an interview. The interview form that needs to be

completed is enclosed in your application packet. The following are the interview, training and additional requirements for each subbing area:

Drivers: Must possess a current commercial driver’s license (CDL), submit a current driving record and be currently participating in the School District’s or another company’s federally mandated Drug and Alcohol testing program.

Nutrition Services: Required to receive necessary training and interview through Nutrition Services. To arrange, contact the Nutrition Services Department at 861-5100.

Nurses: Required to be interviewed by Health Services and must possess a Registered Nurse License. All applicants are screened before they are activated. To arrange, contact the District’s Nurse Health Services Coordinator at 495-9300.

Teachers: Are required to have received a high school diploma or GED a minimum of 3 years prior. Required to be interview by an appropriate MSBSD Administrator. To arrange, contact Human Resources at 746-9200. If you hold a current valid Alaska Teaching Certificate, you are entitled to the higher rate of pay which will begin as soon as the Human Resources Department receives a copy of your certificate. (NO PAY INCREASES WILL BE RETROACTIVE). Certified Teachers: Only those teachers who currently hold a current valid Alaska Teaching Certificate are eligible to fill long-term substitute jobs. A copy of your current valid Alaska Teaching Certificate must be on file in the Human Resources Department. You must sign the Long Term Substitute form available at the school. Clerical/Aides: Required to have a High School Diploma and complete an interview with a Principal. Attached you will find a listing of MSBSD Principals along with the contact phone numbers for arranging an interview. Custodians: Required to complete necessary training and an interview with the Operations and Maintenance Department. To arrange, contact the Department at 864-2011.

SUBSTITUTE APPLICATION

FULL LEGAL NAME SOCIAL SECURITY NO.

MAILING ADDRESS CITY, STATE, ZIP

HOME PHONE NUMBER CELL PHONE NUMBER

EMERGENCY CONTACT INFORMATION

NAME RELATIONSHIP CONTACT NUMBER

PLEASE ANSWER THE FOLLOWING QUESTIONS:

CHECK HIGH SCHOOL DIPLOMA, GED, OR NONE.

HS DIPLOMA GED NONE YEAR RECEIVED DIPLOMA OR GED: _______________ High School Name: ________________________________ City & State: ______________________

DO YOU HAVE AN ALASKA TEACHING CERTIFICATE? Yes No Expiration Date: _____________

Please attach to application to qualify for higher rate of pay. DO YOU HAVE A FOUR YEAR BACHELORS DEGREE

Yes No Please attach transcripts for higher rate of pay. Copies of diplomas will not be accepted.

Are you currently retired from the Teachers’ Retirement System (TRS) or the Public Employee Retirement System (PERS) in the State of Alaska? Yes_____ No_____ If yes, date of retirement: ________________ If no, you are required to complete the included State of Alaska Supplemental Annuity Plan (SBS) form. Are you a current MSEA employee? Yes_____ No_____

College/University: Major:

Teaching Endorsement:

Highest education degree held:

Minor:

PLEASE INDICATE THE SUPPORT STAFF POSITION(S) YOU ARE WILLING TO SUBSTITUTE:

Clerical Food Service

Special Ed Assistant

Day Care Worker

Custodian/ Building

Tutor/Advisor

Delivery Driver* CDL Required School Monitor

PLEASE INDICATE TEACHING POSITION(S) YOU ARE WILLING TO SUBSTITUTE: (PLEASE NOTE THAT ALL SUBSTITUTES MUST HAVE GRADUATED FROM HIGH SCHOOL A MINIMUM OF 3 YEARS IN

ORDER TO SUBSTITUTE IN A TEACHING POSITION)

Classroom Teacher Preschool Teacher

Librarian

Special Ed Teacher

Nurse ELL Teacher

Names of any relatives by blood or marriage who are employed by the Matanuska-Susitna Borough School District (MSBSD) or who serve on the MSBSD Board of Education

Name Relationship Department/Building Name Relationship Department/Building

EMPLOYMENT HISTORY Employment Dates: Job Title:

Employer Name & Address:

Phone: Supervisor:

Employment Dates: Job Title:

Employer Name & Address:

Phone: Supervisor:

PROVIDE 3 REFERENCES ABLE TO ATTEST TO YOUR SUITABILITY AS A SCHOOL EMPLOYEE (NOT RELATIVES);

1. Name: Phone:

2. Name: Phone:

3. Name: Phone:

CERTIFICATION OF APPLICATION 1.) Have you ever been involuntarily released, non-retained, or asked to resign for any reason? ____Yes ____No If yes, describe in full, and list the position: __ ___________ 2.) Have you ever been convicted of, or received a suspended imposition of sentence for, a misdemeanor? ____Yes ____No If yes, describe in full and list the date, city and state in which convicted. ________________________________________________________________________________________________________________________________________________________ 3.) Have you ever been convicted of, or received a suspended imposition of sentence for, a felony? ____Yes ____No If yes, describe in full and list the date, city and state in which convicted. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________ BY SIGNING THIS APPLICATION I HEREBY CERTIFY that all information made on or in connection with this application is true and complete to the best of my knowledge and belief and that I have not knowingly withheld any fact or circumstance. I understand that any misrepresentation or concealment of material fact will be sufficient grounds for rejection of my application or my removal from employment. An inquiry may be made to include confirmation and information as to my character, general reputation, personal characteristics, previous employers, educational background, current and previous residence locations for the past five years, military service and conviction records. I have never been involuntarily released from any position, non-retained, nor have I been asked to resign for any reason. I have not committed any criminal act of child abuse or molestation or any sexual abuse of a minor; any act involving the illegal use or abuse of a controlled substance; any criminal act involving the use or abuse of alcohol; or any other crime of immorality (which means any act involving a crime of moral turpitude under the Laws of the State of Alaska). If I have been involved in any of the situations listed above, I have attached to this application a description of the events and an explanation why I believe such situation should not adversely affect my application for employment. I authorize my present and previous employers and listed references to release to the MSBSD any information they may have regarding my character, background, or my employment record. I release these individuals and their agents from any damage or claim for furnishing said information. I am aware that Alaska Statute 12.62.160 provides that an employer may obtain from the Alaska Commission on Criminal Justice a record of all convictions, and that a favorable record check will be a condition of any offer of employment made by the MSBSD. I understand that employment with the MSBSD requires the approval of the Human Resources Director or designee. Employment offers are made only by the District’s HR Department and must be ratified by the School Board. ___________________ Signature Date THE MATANUSKA-SUSITNA BOROUGH SCHOOL DISTRICT IS AN EQUAL OPPORTUNITY EMPLOYER AND COMPLIES WITH TITLE IX OF THE EDUCATION AMENDMENT ACT OF 1972, with the Americans with Disabilities Act, and with all other state and federal employment laws. The District does not discriminate against any person on the basis of race, religion, color, national origin, age, disability, gender, and marital status, changes in marital status, pregnancy or parenthood. Should you need any assistance for any reason during any stage of the employment process, please discuss your needs with a member of the Human Resources Staff. Every effort will be made to reasonably accommodate you in this process.

THIS PAGE INTENTIONALLY LEFT BLANK

EQUAL EMPLOYMENT OPPORTUNITY SURVEY

NAME: LAST FIRST M.I. SOCIAL SECURITY NUMBER

TO ALL APPLICANTS:

We consider all applicants for positions without regard to race, color, religion, gender, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/national guard or any other similarly protected status. We also comply with all applicable laws governing employment practices and do not discriminate on the basis of any unlawful criteria. This survey is to be completed by applicant on a voluntary basis. Not for interview purposes. To be filed separately from application. APPLYING FOR:

RACE, ETHNICITY, AND GENDER INFORMATION

MALE FEMALE Alaska Native ............................ (D) (P) American Indian/Native American (A) (K) Asian or Pacific Islander ............ (B) (L) African-American ....................... (C) (O) Hispanic ..................................... (E) (S) White ......................................... (H) (T)

DEFINITIONS OF RACIAL/ETHNIC GROUPS The racial/ethnic groups for State affirmative action programs and federal reporting purposes are defined as follows: ALASKAN NATIVE: Any person having origins in any of the original peoples of Alaska, and who maintains

cultural identification through tribal affiliation or community recognition. Alaskan Native may include, for example, any person of Yupik, Inupiate, Aleut, Athabascan, Tlingit, Haida, or Tsimshian origin.

AMERICAN INDIAN/ Any person having origins in any of the original peoples of North America (not including NATIVE AMERICAN: Alaska), and who maintains cultural identification through tribal affiliation or community recognition. ASIAN OR PACIFIC Any person having origins in any of the original peoples of the Far East, Southeast ISLANDER: Japan, Asia, the Indian Subcontinent, or the Pacific Islands. This area includes, for example, China, Korea, the Philippine Islands and Samoa. AFRICAN-AMERICAN: (not of Hispanic origin); any person having origins in any of the black racial groups of

Africa. HISPANIC: Any person of Mexican, Puerto Rican, Cuban, Central or South American, or other

Spanish culture or origin, regardless of race. WHITE: (not of Hispanic origin); any person having origins in any of the original peoples of

Europe, North Africa, or the Middle East.


MSBSD Page 1 of 1 Substitute Action Form 20120702

MATANUSKA-SUSITNA BOROUGH SCHOOL DISTRICT

SUBSTITUTE ACTION FORM

DATE FULL LEGAL NAME SOCIAL SECURITY NO.

MAILING ADDRESS CITY, STATE, ZIP PHONE

DATE OF BIRTH

MARITIAL STATUS

ETHNICITY

SEX

SPOUSE NAME

**********OFFICE USE ONLY – DO NOT COMPLETE ANY SECTION BELOW**********

MUNIS ID NO.

EFFECTIVE DATE FROM

EFFECTIVE DATE TO

HIGH SCHOOL COMPLETION VERIFICATION PROVIDED DOCUMENTATION DID NOT PROVIDE DOCUMENTATION MSBSD GRADUATE

GRADUATION DATE:

REGISTRAR NAME (PRINT): REGISTRAR SIGNATURE:

EXT. ID 3 EXT. ID 4 TITLE BASE RATE NON-DEGREE NON CERT/ DEGREED – TCHR POSITIONS $ 9.00 SUB FOR EMPLOYEES IN PAY GR. 1-5 $ 9.00 SUB FOR EMPLOYEES IN PAY GR. 6-9 $11.60 SUB FOR EMPLOYEES IN PAY GR. 10-14 $13.66 DRIVER DELIVERY DRIVER $14.30 WAREHOUSE INVENTORY SPECIALIST $14.30 DEGREE NON CERT W/ BA-BS DEGREE –TCHR POS. $16.00 CERTIFIED CERTIFIED SUB – ALL POSITIONS $20.00 NURSE CERTIFIED NURSE $22.00 SUMMER O & M SUPERVISOR $16.53 TEMP WKR 1YR I.T. INTERN $10.00 POOL NURSE POOL NURSE SUB $24.00 WELDING INSTRUCTOR $25.00 INCENTIVE SUBSTITUTE TRAINING INCENTIVE $ 0.67

COMMENTS

HR Entered Date:

Entered By:


][STD FBENED ][04/23/13 ][Page 1 of 2 ][B01:010713][GP22/321117602

Beneficiary Designation401(a) Plan

Use black or blue ink when completing this form. For questions regarding this form, contact Service Provider at 1-800-232-0859.

98214-03 State of Alaska Supplemental Annuity Plan

A Participant InformationAccount extension identifies funds transferred to abeneficiary due to death, alternate payee due to divorce

Social Security Number Account Extension or a participant with multiple accounts.

/ /Last Name First Name M.I. Date of Birth

( )Street Address Personal Phone Number

( )City State Zip Code Work Phone Number

Email Address ❑ Married ❑ Unmarried

Division/Payroll Center

B Primary Beneficiary Designation (Attach an additional sheet to name additional beneficiaries.)

If I am married, my Plan requires my spouse as primary beneficiary for at least 50% or my spouse consents to my beneficiary designation.

% / /% of Account Balance Primary Beneficiary Name Relationship Social Security Number Date of Birth

Street Address City State Zip Code





Contingent Beneficiary Designation

% / /% of Account Balance Contingent Beneficiary Name Relationship Social Security Number Date of Birth






C Signatures and Consent

Participant Consent

I have completed, understand and agree to all pages of this Beneficiary Designation form. Subject to and in accordance with the terms ofthe Plan, I am making the above beneficiary designations for my vested account in the event of my death. If I have more than one primarybeneficiary, the account will be divided as specified. If a primary beneficiary predeceases me, his or her benefit will be allocated to thesurviving primary beneficiaries. Contingent beneficiaries will receive a benefit only if there is no surviving primary beneficiary, as specified. Ifa contingent beneficiary predeceases me, his or her benefit will be allocated to the surviving contingent beneficiaries. If I fail to designatebeneficiaries, amounts will be paid pursuant to the terms of the Plan or applicable law. This designation is effective upon execution anddelivery to Service Provider. If any information is missing, additional information may be required prior to recording my designation.

This designation supersedes all prior designations. Beneficiaries will share equally if percentages are not provided and any amounts unpaidupon death will be divided equally. Primary and contingent beneficiaries must separately total 100% in whole percentages.

98214-03

Last Name First Name M.I. Social Security Number Number

][STD FBENED ][04/23/13 ][Page 2 of 2 ][B01:010713][GP22/321117602

I understand that Service Provider is required to comply with the regulations and requirements of the Office of Foreign Assets Control,Department of the Treasury ("OFAC"). As a result, Service Provider cannot conduct business with persons in a blocked country or anyperson designated by OFAC as a specially designated national or blocked person. For more information, please access the OFAC Web siteat: http://www.treasury.gov/about/organizational-structure/offices/Pages/Office-of-Foreign-Assets-Control.aspx.

Important Notice: If I am married and I elect a primary beneficiary other than my spouse or in addition to my spouse, my spouse mustconsent by signing the Spousal Consent section of this form.

Any person who presents false or fraudulent information is subject to criminal and civil penalties.

Participant Signature Date (Required)

Spousal Consent

Dates of the participant’s spouse signature and notarization or witness by Plan Administrator/Trustee must match.

I, (name of spouse) , the current spouse of the participant, hereby voluntarilyconsent to the participant’s primary beneficiary designation above and understand its effect. I understand that by providing such consent Iam waiving my right to receive either all (if I am not designated as a primary beneficiary) or a percentage (if I and another person aredesignated as primary beneficiaries) of the participant’s vested account which would otherwise be payable to me upon the participant’sdeath. I understand that my consent is irrevocable unless my spouse changes beneficiary designation, or designates me as a primarybeneficiary to receive his or her entire vested account balance.

Spouse Signature Date (Required)

Witness of Spouse’s Signature

The spouse’s signature must be witnessed by a Notary Public or Plan Administrator/Trustee (see below).

This form may also be signed in front of a Postmaster or Division of Retirement and Benefits Representative.

Statement of Notary NOTE: Notary seal must be visible.

State of ) The consent to this request was subscribed and sworn (or affirmed)to before me on this day of , year , by

Judicial )ss. (name of spouse)District or proved to me on the basis of satisfactory evidence to be the person who SEALCounty of ) appeared before me, who affirmed that such consent represents his/her free

and voluntary act.

Notary Public Signature My commission expires

Authorized Plan Administrator/Trustee Signature

I accept the information provided by the participant on this form.

If notarized consent is not obtained, I certify that the Spousal Consent was signed by the spouse of the participant in my presence.

Authorized Plan Administrator/Trustee Signature Date (Required)

D Mailing Instructions

Participant forward to EmployerEmployer forward to Service Provider

Great-West Retirement ServicesRegular Mail:PO Box 173764Denver, CO 80217-3764

Phone: 1-800-232-0859Fax: 1-303-801-5800Website: www.akdrb.com

Express Mail:8515 E. Orchard RoadGreenwood Village, CO 80111

Form SSA-1945 (01-2013) Destroy Prior Editions

Social Security Administration

Statement Concerning Your Employment in a Job Not Covered by Social Security

Employee Name Employee ID#

Employer Name Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.”

For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits.

Signature of Employee Date


Form SSA-1945 (01-2013)

Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security

New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.

Employers must:

• Give the statement to the employee prior to the start of employment;

• Get the employee’s signature on the form; and

• Submit a copy of the signed form to the pension paying agency.

Social Security will not be setting any additional guidelines for the use of this form.

Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at [email protected] or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer. Forms will not be sent to a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.



PAYROLL DEPARTMENT


501 N. Gulkana E-Mail: [email protected] Ph: 907.761.4025 Palmer, Alaska 99645-6147 www.matsuk12.us Fax: 907.761.4084

PAYROLL DIRECT DEPOSIT FORM LAST NAME FIRST NAME MIDDLE NAME

ID NO. OR SSN DAYTIME PHONE NUMBER

ELECTRONIC FUND TRANSFER (EFT) AUTHORIZATION Authorizations can be made for both net pay deposits and up to two flat amount deposits. I hereby authorize the MSBSD to make payroll deposits to my account as indicated below: Please use the complete routing and account numbers, including preceding zeros. Failure to provide the full number could result in processing delays.

I authorize the MSBSD to initiate, if necessary, debit entries and adjustments for any credit entries made in error to the account (s) I have

indicated above. I understand the MSBSD will make a reasonable effort to notify me within twenty-four (24) hours if a debit entry or adjustment is made against the account. This authority is to remain in full force and effect through the duration of my employment with MSBSD or until MSBSD has received written notification from me. I understand I must notify the MSBSD immediately and complete a new authorization form if I change financial institutions, account numbers or type of account. Submit this completed form to the Payroll Department for processing. The processing of this form can take two (2) pay periods. Any alteration or unauthorized addition invalidates this form.

________________________________________ _______________________________

Signature Date

Initial Authorization Change Cancellation No Change NET PAY DEPOSIT CHECK ONLY ONE

Checking Savings Financial Institution Name & State: Institution Transit Routing Number:

Account Number

Initial Authorization Change Cancellation No Change 1ST FLAT AMT DEPOSIT $ CHECK ONLY ONE


Account Number

Initial Authorization Change Cancellation No Change 2nd FLAT AMT DEPOSIT $ CHECK ONLY ONE


Account Number

PAYROLL DEPARTMENT


501 N. Gulkana E-Mail: [email protected] Ph: 907.761.4025 Palmer, Alaska 99645-6147 www.matsuk12.us Fax: 907.761.4084

DISTRICT DIRECT DEPOSIT FORM INSTRUCTIONS

Enter ID Number or SSN and Full Legal Name NET PAY DEPOSIT To deposit the net dollars from each pay warrant for each pay period. Dollars can be transferred to any ACH participating Financial Banking Institution.

Indicate by marking the appropriate box: Initial Authorization – you do not currently have an existing electronic NET deposit. Change – you wish to make a change to an existing electronic NET deposit such as a new financial institution, account number or account type. Cancellation – you wish to cancel an existing electronic NET deposit and elect not to have a new set-up started. No Change – you wish to continue your existing electronic NET deposit. Mark this box if you are making an authorization in the flat amount deposit section only.

Enter the name of the financial institution, the 9-digit institution transit routing number, and account number. Indicate either Savings or Checking. Only indicate ONE type of account. Monies may not be divided between savings and checking.

FLAT AMOUNT DEPOSIT A set flat amount of money can be electronically deposited into any ACH participating financial institution.

Indicate by marking the appropriate box: Initial Authorization – you do not currently have an existing electronic flat amount deposit. Change – you wish to make a change to an existing electronic flat amount deposit such as a new banking institution, account number, account type or dollar amount. Cancellation – you wish to cancel an existing electronic flat amount deposit and elect not to have a new set-up started. No Change – you wish to continue your existing electronic flat amount deposit. Mark this box if you are making an authorization in the NET deposit section only. Enter the name of the financial institution, the 9-digit institution transit routing number, and account number. Enter the dollar amount – Enter the flat dollar amount to be deducted from the appropriate pay period. Indicate either Savings or Checking. Only indicate ONE type of account. Monies may not be divided between savings and checking. Sign and date the form. Submit the completed form through ESS to your Payroll Department. When to expect your first deposit: Each new deposit or change may require at least two pay periods processing time. It is recommended that the payee maintain accounts at both financial institutions or accounts when change is initiated until the change has been fully implemented on the MSBSD Payroll System. Additionally it is highly recommended that the checks, withdrawals, automatic payments are not set up until the new account requested is fully functional.



MSBSD Page 1 of 1 Substitute Interview Form

SUBSTITUTE INTERVIEW FORM

Applicants for substitute nursing positions must be interviewed by Health Services. To arrange, contact the District’s Nurse Health Services Coordinator at 495-9300.

Applicants for food service positions must be interviewed by a Supervisor of the Food Service Department. To arrange, contact the Department at 861-5100.

Applicants for custodial positions must be interviewed by a Supervisor of the Operations and Maintenance Department. To arrange, contact the Department at 864-2011.

Applicants for teaching and general support staff positions outside of those listed above must be interviewed by an Administrator. To arrange, contact Human Resources at 746-9200.

Applicant Name (Please Print)

General Ed Teacher Delivery Driver

Special Education Teacher Clerical/School Aide

Special Education Assistant School Monitor

Food Service Custodian

Other _____________________________ Nurse I have interviewed the above applicant for the position of substitute and recommend:

Acceptance in marked areas only Non-acceptance at this time

____________________________ Printed Name ____________________________ Signature /Title Date Comments:

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________




MSBSD Page 1 of 2 Fingerprinting Form

FINGERPRINTING FORM

You may contact any fingerprinting service provider but they must be able to complete the following or your cards will not be accepted

a. Complete one fingerprint card. b. Fill out the fingerprint card with the correct applicant and district information. c. Collect the State and Federal Service Charge for Fingerprint processing,

total $51.50. d. Send the card along with the above mentioned fee to the State of Alaska

Department of Public Safety. The following are Fingerprinting Service Providers who have agreed to complete each of the requirements listed. The cost includes the $51.50 processing fee. Name Cost Contact Phone Meadow Lakes City Center $84.00 (907) 373-6245 UPS Store Mile 49 Parks highway Hi-Tech Fingerprints $85.00 (907) 563-4659 Anchorage, AK MSBSD $70.00 *Cash or Check Only (907) 746-9200 By Appointment only – Tuesday, Wednesday, or Thursday 8:00 am – 11:00 am. *Please have exact change for payments in cash. 2. Fingerprinting Certification I certify that ___________________________________ was fingerprinted on Individual Name (please print) ______________________. Date

__________________________ ____________________ Fingerprinting Official (please print) Organization


Business and Non-Instructional Operations BP 3523-E EMPLOYEE TERMS AND CONDITIONS FOR RESPONSIBLE USE OF MATANUSKA-SUSITNA BOROUGH SCHOOL DISTRICT INFORMATION TECHNOLOGY RESOURCES (continued) employee’s own risk. The District specifically denies any responsibility for the accuracy of information obtained through District electronic information resources. Results of Inappropriate Use of District Information Technology

use of District information technology is a privilege, not a right, and ivileges. District system

ministrator(s) have the authority to determine what constitutes appropriate and/

olicy may be directed to the District’s Chief Information Officer.

e read, understand, and agree with the Employee erms and Conditions for Responsible Use of Matanuska-Susitna Borough School

formation Technology Resources. I further understand my failure to follow

Employee inappropriate use shall result in cancellation of those prad orinappropriate use of District technology and may restrict employee access to District technology at any time, as required. Appeals Appeals to this p Employee Agreement for Responsible Use of Matanuska-Susitna Borough School District Technology Information Resources My signature below indicates I havTDistrict Inthese stated terms and conditions may result in disciplinary action, up to and including termination, and/or appropriate legal action. I agree to report any misuse of District information technology resources to the appropriate District technology official. Misuse comes in many forms and shall be viewed as any messages sent or received that include/suggest pornography, unethical or illegal solicitation, racism, sexism, nappropriate language, and other issues described herein. I understand all rules of iconduct described herein apply when I am using District information technology resources, including social media and social networking sites.

mployee’s Printed Name Employee’s Job Title/Work LocaE tion Employee’s Signature Date

Page 5




MSBSD Page 1 of 1 Substitute Terms of Employment and Receipt of Policies

SUBSTITUTE POSITIONS

1. TERMS OF EMPLOYMENT

All substitutes are “at will”, on call, temporary employees, and can be dismissed at any time for

any reason deemed appropriate by the District. You will be on the active substitute list for this entire school year (July 1 to June 30), unless you send in a written note asking to have your name removed from the active sub list. You have reasonable assurance of being called on any regular workday. Holidays, vacation days, and summer vacation are just like a weekend and you will not be called to work those days. During the summer, in order to update our records, you may be asked to verify your interest in continuing to substitute.

________________________________________ _____________________________

Printed Name Date

_______________________________

Signature

2. RECEIPT OF POLICY

I have received a copy of the following MSBSD policies:

Drug Free Workplace and Drug Free Schools Policy – BP 4020 Equal Employment Opportunity – BP 4119.11 EEO Complaint Procedure – AR 4119.11(a, b) Sexual Harassment – A Guide for Faculty, Staff and Students. Terms of Employment

________________________________________ _____________________________

Printed Name Date

_______________________________

Signature


\

MSBSD Test Security Agreement

According to regulation 4 AAC 06.765 (f) “school and district personnel responsible for test administration shall annually execute an agreement, on a form provided by the department (district), affirming that they will follow the test procedures required under this section.” The Code of Ethics and Teaching Standards (20 AAC 10.020) requires educators to “cooperate in the statewide (district-wide) student assessment system.”

Test security is essential to obtain reliable and valid scores. Accordingly, the Matanuska-Susitna Borough School District (MSBSD) must take every step to assure the security and confidentiality of testing materials. It is the responsibility of individuals who handle the tests, who administer tests, and/or who use the results of the test to follow test security regulations and procedures. Listed below are required procedures for handling test materials. Please read each statement carefully and initial each line to indicate that you agree to follow these procedures. Please sign your full name at the end of this form. If you have any questions about test security or about any of the procedures listed below, please contact the Assessment Coordinator at 907.761.4020.

*****ALL TESTING PERSONNEL*****

*Your initials indicate that you have read and understand the provisions of this agreement.*

Please read each provision below and initial. Initials 1. Before administering any tests, I will deliver this properly signed Test Security Agreement to the appropriate personnel. [4 AAC 06.761 (c)]

2. I have read and understand the attached regulation 4 AAC 06.765. Test security; consequences of breach.

3. I understand that my actions may be subject to investigation and adjudication by the Professional Teaching Practices Commission if I violate any of the provisions detailed in regulation 4 AAC 06.765.

4. I am employed by the Matanuska-Susitna Borough School District as an administrator, teacher, classified staff, or substitute.

5. I will not read test items aloud, silently, to myself, or to another individual, unless specifically required to provide an accommodation to an individual or student group. [4 AAC 06.765 (b)]

6. I shall maintain the security and confidentiality of electronic test data files, individual student reports, and other testing reports designated as secure. [4 AAC 06.765 (g)]

During handling of test materials for which I am responsible, I will: 7. Code the tests according to test administration directions before testing. [4 AAC 06.765 (d)(1)] Mark N/A if this is not part of your duties.

8. Inventory and track test materials from the time the materials arrive at my classroom or school until the time the materials are returned to the district. [4 AAC 06.765 (d)(2)] Mark N/A if this is not part of your duties.

Initials 9. Control the storage, distribution, administration, and collection of tests. [4 AAC 06.765 (c)(4)]

10. Securely store tests before and after each testing session. [4 AAC 06.765 (d)(3)]

At the Test Center, to the best of my ability and within the scope of my responsibility, I will exercise due diligence to: 11. Complete training in test procedures provided by my district; read and follow all testing procedures and manuals published by the test publisher, unless instructed otherwise by the district. [4 AAC 06.765 (f)(2-3)]

12. Ensure that no test or test question is copied, reproduced, or paraphrased in any manner, by an examinee or anyone else, whether on paper or by electronic means. [4 AAC 06.765 (c)(5) and (d)(5)]

13. Ensure that examinees use only those reference materials allowed by the test publisher’s testing procedures. [4 AAC 06.765 (d)(6)]

14. Ensure that examinees do not exchange information during a test, except when the test procedure so specifies. [4 AAC 06.765 (d)(8)]

15. Ensure that examinee’s answer is not altered after testing is completed. [4 AAC 06.765 (d)(9)]

16. Ensure that no examinee is assisted in responding to or review of specific test questions or items before, during, or after a test session. [4 AAC 06.765 (d)(10)]

17. Ensure that no individual (including but not limited to other proctors, test administrators, teachers, parents/guardians, administrators) receives a copy of the test or learns of a specific test question or item, before the test date and time set by MSBSD, unless knowledge of the question or item is necessary for delivery of documented accommodations under 4 AAC 06.775. [4 AAC 06.765 (d)(7)]

18. Not open student test materials before, during, or after testing for any reason, except as required to deliver documented accommodations. [4 AAC 06.765 (b)]

19. Report any potential breach of test security [4 AAC 06.765(h)] or violation of Alaska Administrative Code (AAC) to the district office through the appropriate district/school personnel.

20. Assist, as needed, the designated district personnel in charge of testing in making my school test center secure, keeping it free of disruptions, establishing a seating arrangement, and seeing that it is well lighted. [4 AAC 06.755 (b)]

A teacher holding a certificate issued under 4 AAC 12 who breaches security as described in this agreement is subject to investigation and adjudication by the Professional Teaching Practices Commission. [4 AAC 06.765(e)] I have read and understood all of the above procedures and agree to follow them strictly in order to protect the security of restricted test materials. I affirm that the test procedures of the Matanuska-Susitna Borough School District will be followed. Any infraction of these provisions will result in removal from the MSBSD substitute list.

______________________________ _____________________ Signature Date ______________________________ First and last name printed clearly

Elective Deferral and Vendor Election Instructions You can use the website to make changes in the amount you wish to defer, as well as to make changes in your vendors. The CPI Participant Website can be accessed 24 hours a day, 7 days a week. If you do not have internet access you can enroll in the 403(b) plan maintained by Matanuska-Susitna Borough School District using the Elective Deferral and Vendor Election Form which can be obtained by contacting the CPI Participant Service Center at (877) 488-4040. New employees must complete all sections. Current participants need to complete the applicable sections to make changes to their current elective deferral amounts or their vendor(s). The instructions for each section of this form are provided below:

At the top of the form, the eligible Employee/Participant should check one of the options to indicate the reason for completing the form in order to ensure complete processing.

Sect

ion

A Your Info

All Employees/Participants completing this form must enter the information requested in this section as indicated so that they will be properly identified as the originator of the election form.

Sect

ion

B

Your Election New Employees must complete this section and indicate the dollar amount they wish to contribute to the plan or as a 457(b) Contribution. Current Participants should complete this section if they wish to change the dollar amount they are currently deferring to the plan or as a 457(b) Contribution.

Your deferrals will start once your Employer has had sufficient time to update their payroll system. If you do not see your deferral starting within a reasonable time, please contact your Employer.

Sect

ion

C

Your Vendor Direction The vendors approved to receive current contributions are listed in each section. New Employees enrolling in the plan must complete this section of the form to choose the vendors to which they wish to invest contributions and to indicate the dollar amount that will be allocated to each vendor. Current participants should complete this section if they wish to make changes with whom they are investing their contributions. You must also indicate the account/contract number to which the monies are being allocated with the appropriate vendor. This information should be provided to you by the vendor at the time you opened the account/contract. If you have not established the account/contract, you cannot select the new vendor at this time. Once this information has been provided, CPI will input the election(s) amount along with the vendor(s) you have chosen for such allocations. Participants should complete the Employer section(s), whether or not they are eligible. Since Matanuska-Susitna Borough School District will be determining the amount to be allocated, we ask that you indicate the percentage that is to be allocated to each vendor.

Sect

ion

D Sign

New employees and current participants should read this section carefully and sign where indicated in order for their election(s) to take effect.

Mailing Instructions:

Upon completion of the Elective Deferral and Vendor Election Form, the form should be mailed, faxed, scanned or e-mailed to the following address: CPI Common Remitter and Compliance Services 1809 24th Street Great Bend, KS 67530 Fax: (620) 792-5622 E-mail: [email protected]

If you need assistance completing this form, you can call our Participant Service Center (877) 488-4040 from 7 a.m. to 7 p.m. Central Time, Monday through Friday. You can also send and e-mail to [email protected]. For prompt assistance, please have your six-digit plan reference number 105928, the last four digits of your social security number and date of birth available.

CPI CRS Form 13-132, Revised 09/29/11

Elective Deferral and Vendor Election Form

Plan Name: Matanuska-Susitna Borough School District 403(b) Plan Ref. No. 105928

To Enroll: Complete All Sections To Change Contribution Amount: Complete Sections A, B, C and D

To Change Vendors: Complete Sections A, C and D To Change Contract/Account Number: Complete All Sections

Se

cti

on

A

Yo

ur

Info

Please type or print clearly

--

Last Name First Name M. I. Social Security Number (SSN)

Email Address: Daytime Phone Number: ( )

Se

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on

B

Yo

ur

Ele

cti

on

Salary Deferral – I instruct my employer to deduct $__________ of my pay on a pre-tax basis each pay period for investment with the specified vendors below.

(In the space provided, enter a dollar amount.)

457(b) Deferral – I instruct my employer to deduct $________ of my pay each pay period for investment with the specified vendors below into the designated 457(b) portion of my account.

(In the space provided, enter a dollar amount.)

Se

cti

on

C

Yo

ur

Ve

nd

or

Dir

ecti

on

Please indicate how you are making your salary deferral election: as a dollar amount

I direct that all future contributions be invested with the following vendor(s). Enter a dollar amount. If you have not established the account/contract, you cannot select the new vendor at this time.

Vendor Name

Amount

Account/Contract

Number

American Fidelity Assurance Company

Aspire Financial Services, Inc.

Fidelity Investments

Horace Mann Companies

ING Reliastar

Lincoln Financial Group

MetLife

Oppenheimer Funds

Security Benefit Group of Companies

Symetra Financial

The Legend Group - ADSERV

Thrivent Financial for Lutherans

Vanguard

Waddell & Reed Financial Services

Total Dollar Amount

CPI CRS Form 13-132, Revised 09/29/11

Se

cti

on

C

Yo

ur

Ve

nd

or

Dir

ecti

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457(b) Deferral - Please indicate below which vendor(s) you would like for 457(b) deferral to be invested with by providing the name of the vendor(s) and the dollar amount that is to be allocated.

I direct that all future employer matching contributions be invested with the following vendor(s). Enter whole percentages in multiples of 1%. i.e., 25%, 50%, 100%. Total percentage amount must equal 100%.

Vendor Name Amount Account/Contract Number

American Fidelity Assurance Company

Aspire Financial Services, Inc.

Horace Mann Companies

ING Reliastar

Lincoln Financial Group

MetLife

Security Benefit Group of Companies

Symetra Financial

The Legend Group - ADSERV

Waddell & Reed Financial Services

Total Dollar Amount

Se

cti

on

D

Sig

n

By signing this form, I have authorized the Employer to deduct the amount(s) elected from my paycheck and transmit the contributions to the vendors as indicated. I certify that I have established a 403(b) account with the vendors selected above.

Participant Date


APPROVED 403(b) and 457(b) PLAN VENDOR LIST

Plan Name: Matanuska-Susitna (Mat-Su) Borough School District - 403(b) and 457(b) Plan Plan Sponsor: Matanuska-Susitna (Mat-Su) Borough School District Effective Date: 01/09/2012 Ref. No.: 105928

This list identifies the investment vendors available under the 403(b) and 457(b) plan maintained by Matanuska-Susitna (Mat-Su) Borough School District - 403(b) and 457(b), on or after the effective date of this list. The information can also be found on the CPI Participant Website. After you have logged onto the site using your User Name and Password, click on “Plan Contacts” near the top right of the screen. A new screen will appear that will contain the list of vendors. By clicking on the arrow to the left of the vendor’s name, you will be able to view the contact information. A. The following Vendors are authorized to receive contributions and contract exchanges between vendors under the 403(b) and 457(b) Plan:

Name of Vendor

Contact Information for Local Investment Representative

American Fidelity Assurance Company General Number (800) 450-3506 Aspire Financial Services, Inc. General Number (866) 634-5873 Fidelity Investments General Number (800) 544-4774 Horace Mann Companies General Number (866) 999-1945 ING Reliastar General Number (877) 882-5050 Lincoln Financial Group General Number (800) 454-6265 Oppenheimer Funds General Number (800) 835-7305 Security Benefit Group of Companies General Number (800) 888-2461 Symetra Financial General Number (800) 796-3872 The Legend Group - ADSERV General Number (888) 883-6710 Thrivent Financial for Lutherans General Number (800) 847-4836 Vanguard General Number (800) 523-1036 Waddell & Reed Financial Services General Number (888) 923-3355

mailto:[email protected]�
















Documents

HUMAN RESOURCES Katherine Gardner, Director · _____ Transcripts stating conferred date of Bachelors degree or Alaska Teaching Certificate (to receive the higher rate of pay). Note: