Document v6VOBgVZzkEbpjoEr58M0RqaY
CY-RI 006962
ILLINOIS
CY-RI 006963
w
^Option 2
xn
Instillments
Option 3 N^J
LumpSum
Jn installments of(oiniaM^4^^nOu' thereby designate the.followingts~
-4MPtC4AAY ttfUflt
F?Mto,'-gSSO,3no ^equafmdnthlypeyments. -
-iMW
-- -66M.aECURmr n o .
------------------------------------------------------------------------ XBBRIS----------- -----------------------------------------------With regain to the values of the Company Stock Fund to which I emontitted, l fleet
Cash, which will be included in the monthly installments Equivalent Shares of Company Stock
In e lump sum.
With regerd to the values of the Compeny Stock Fund to which I am entitled, I elect
^ Cash
Equivalent Share* of Company Stock
In addition, I hereby notify the Plan Administrator that I am making the following Irrevocable election concerning distribution of my
Accounts:
/G Distribution as soon as practicable. (Payment can normally be expected within two (2) months of the effective valuation date.)
Deferred distribution effective as of January 31 next year. I understand my Accounts will continue to share in the investment experience of the funds until January 31 next year. I further understand my account values at that time may be higher or lower because of increases or decreases in the market values of securities held for my account. (Payment can normally be expected within two (2) months of that date.)
AUTHORIZATION
I hereby acknowledge that I have chosen the above method of distribution and authorize payment of my Cyanamid f
s*uinn<
CY-RI 006964
Employs Savings Plan The 4011k) Opportunity Participation Election
AT
Read the Protpcctus related to tha Plan before filling out this form.
AnwrieMi Cyanamid Company
is*-
S PRINTO* TYK.
ttMoage EPt io n ^ ."> ^ ^MP I ATtON
NAME (
.CAt*<rCiJtuirf_____ n/wo/1
t tyna. maca.*Hd<te4nWall
...-fellO-lfa, IILlllA J__ L
I ! t~l .1 i 1 ^ *
iiri^i^i i iL. r,,j,,j J...I
1 i i L.
CURRENT
NUMBER AND STREET
l i^i ^ i Kj i/ m\&A
APT. NO,
'j_L_L
EMPLOYEE ADDRESS
ZJITY
^ li^n K id & lo.i J i i a~7 i < i ii
it
STATE ZIP CODE J-ii.
4n accordance with the Plan provisions I hereby elect to participaat inThe 4014k) ing deductions from my earnings, effective with my first pay datein IMS.
Xloomanytomake die foHow-
1. I elect until further notice to have my total mniiilaiiiiminlliaTIpii ipuMaril
4i .% (1%--13%) of my "Eamings"
.. "
I eiset to have my total contribution allocated inwttoie percentages arfoHowi: -
BEFORE-TAX Matched 3 % (0%-3%)
4
AFTER-TAX Matched -- ~% (0%-3%)
Unmatched ID % (0%-10%) + Unmatched --' % ffl%~lfl%) -
TOTAL
'-Matched
__% (Cannot Exceed 3%)
Unmatched /O % (Cannot Exceed 10%)
4
3. I understand:
The first 3% of my contribution percentage will be matched by. the Company at 0%. but I will not ba tbieto elect any Unmatched Contribution unless my Match Contribution percentage is 3%.
B. I msy discontinue or decrease my Before-Tax percentage contribution as of any enrollment date during 1885. I will not be able to reinstate or increase my Before-Tax contribution percentage for tha remainder of 1985.
C. I may change my After-Tax percentage contribution as of any enrollment date, but not more than twice in any 12 month period.
4. Having elected to participate in The 401 (k) Opportunity as indicated above, I elect to invest my contribution as follows: P Continue my current investment elections unchanged.
Change my investment elections effective with my first pay dats in 1985 in accordance with the attached Investment Change Appli cation Form 6669-05.
This form must be received by your local Personnal/Employee Benefits Department or the Employee Savings Plan Supervisor, American Cyanamid Company, Wayne, NJ. 07470 on or before October 31, 1984 in order for your Before-Tax payroll deductions to become effective in 1985.
I hereby acknowledge that I have received a copy of the Prospectus relating to this Plan and agree to the terms and provisions of the Plan.
DATE
SIGNATURE OF EMPLOYEE
s
^^EWED EY
FOR PLAN ADMINISTRATION USE ONLY
DATE
# $ ^ ytrrnovED F EMPLOt4SAV4N9S P
'suFgpvison
OATE
Deductions commence with payperiod ending:. NAeeee-07 s-aa
PAYROLL
CY-RI 006965
"/TO
fAYtOU CHANGE AUTHO*IZATON
P E WMIO
r t h r e e l in e s s h o u io r e f l e c t e mp l o y ee 's s t a t u s a f t e r c h a n c e is ma d e
2/1/84
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12/17/36
09/16/76
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COMPLETE NEXT TWO LINES FOR MEW EMPLOYEE TRANSFfR SETWEEN PAY POl*
NOW AOMCSS-STKCT
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HAVE Of ABSENCE
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lAST DAf( W0*M?
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REMARKS:
MIN PLUS $105
1 14 MO INTERVAL
RAA**mCn TA. ANC 0*Vj S*ONA AMtOVAlJ AND DAMS
4n--InQ1itP.. 4DA**.T.
COn t E Ov G*OU
FOR PAYROLL DEPARTMENT USE
ATIOU N'JMlif
CY-RI 006967
MPOCNCI :0Df
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PAYROLL CHANGE AUTHORIZATION
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^
12/01/82
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12/01/36 , 09/16/76
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12/01/82
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AUTHOwao tv
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RATING_____
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REMARKS*
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LAST OAtf WORCCO
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. MIN PLUS $217
ORPARTm|NTAl AMO DIVISIONAL APPROVALS ANO OAT|S
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FOR PAYROLL DEPARTMENT USE
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LOCATION COM
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CONTROL!***
CY-RI 006968
fJiSfNCt COM
MYROU. CHANGE
tuv uwxP o r izP n yz z{y |}~ ma iw urns wouip wntct tMWOvtrs P P
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12/01/St
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ON A80RESS>STHT
SCI
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5 TERMINATION
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CY-RI 006969
90CMCICOOI
I understand that my matehad payroll deduction cannot ba suspended unless my unmatched payrolldeduction, if any, it euepended at the
-same time or earlier, t further understand that payroll deductions maybe suspended effective*ofany enrollment date.
H
m suvifi h >n nj c(jrj imr.;ni o \t .
Matched Contribution:
Resume my matched contribution at the previous deduction percentage end at the previous investment election authorized, unless a new investment election form is completed and attached hereto..
Unmatched Contribution:
Resume my unmatched contribution at the previous deduction percentage end at the previous investment flection authorized, unless a new investment election form is completed and attached hereto. I understand that no unmatched contribution is permitted unless my matched contribution is 3%.
PAYROLL CHANGE
0*rt
NRMfO
AUTHORIZATION
.......
M>xr THtt LiNts sHom.o renter nwonrs P P EP is P ; o / j 1 / `
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CV-RI 006971
se mj -'WS * '
PAYROLL' CHANCE
^
AUTHORIZATION
//m/01
NEXT THE LINES SHOULD REHECT EMPLOYEE'S STATUS AfTER CHANGE IS P e 6/29/81
fMPlOTff NO
COMPANY 4 OlVlSON
PLANT 0* OP*<l
31*' COM Ofpt P OR SfC'-CN
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12/17/36 ! 09/16/76
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LAST DATS WOCKIO
LEAVE Of ABSENCE
mo m LlAVf OP OSCNCt
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06/08/81 06/15/81
06/08/81 ONUAVt VKt
06/08/81
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06/14/81
LAST DAT* wOKE0
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06/05/81
VARIATION TO NEAREST PNT OP tANOf
REMARKS*
DISABILITY LEAVE OF ABSENCE WITH FULL PAY LESS WEEKLY BENEFITS*
R^PHOATS .
OCPARTMfNTAl ANO 0>VT4<0NAL APPROVALS ANO OATH
A--ntnQVAil 4oDirAT*
CONTROL 04OUP
FOR PAYROLL DEPARTMENT USE
OlSTtiSuTtON
>AROU NU4A4IR
LOCATION COM *
CY-RI 006972
*!J3!n CI ICC! i
OFFICE MEMORANDUM
CY-RI 006973
1
PAYROLL CHANGE AUTHORIZATION
:?r
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AMERICAN CVANAm-C :3
IOUN EtOQ* n .
EmP'CE NO
65'.2 !
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CCDP P D 4 Div is io n
ACCO-OCD
' F`**'.C*CE NAME
'.ANT OR 0*'Cf
CHICAGO
CODE
0299
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0I*T P n O OR SEC'On
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COM.PLST5 NgXT TWC l!Ng5 FO* Ngw gMPlOYgg TftANSfSR SgTWggN PAT POINTS. ANO LANT gMPlOYgg GOING FROM -C'-L? SP .P *****
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Chtck ond complitj appropriate action or sectors bt'ow.
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COMPANY AN* DIVISION
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TRANSFgR *i4C * Miss*
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08/01/80
PgRf. POT. RATING --
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PRESENT BP !P Rv CGP "#$
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0A*S OATS
08/01/79
MO.! TO5
LEVEL
Ex e mpt io n CODE
*NC*'CN
ISO
I----- I i EXEMP* { I : n x emp
CONTINUOUS SERVICE DATE
EEO
ECOmmEn OEO *OR RfNiRI
n'
*
CASON *Ct rf*V>NA*!0N
2 : SC-A*Gf 2
*CCSVj GG*5PP
TiOn 1-Cn
IIT'lt OM*.n -*?*SCn *l
>**
4 *!m*s P *:Sn M.'.Ak
J iA0* OR Ct-MINAT'CN I* iCJ
a m.u TP 67 89@ACEe
i U' |m|mT 9 3CATN
EFHP IPQ of ERSt s ev E * :*
*4.0
6
1: AOCHTfON REPLACE AOV RfPL
AUTHORIZED IV
NAME OR (MPlOVCf UMO REPLACED
iMT DATE WORCCO
REASON LEAVING' >OR TERMINATION
'
'
LEAVE O' AES&NCE
REINSTATE OM
LCAVf Of AlUMCt CVAIUATION SCAII 4 OCORtt
moor REMARKS:
ON lEAVl SINCC
TP UV bP We w o r k e d
rr
XP Y`P aio n TO NEAREST p o in t 0 P cGC
1/3 PLUS $75
3
5%, Wt*
OC**RTmCNTAI AND OlVISIONAL APPROVALS ANQ OATfS
APHP*RsOVRAtLi t:t04'*1
CONTROL GROUP
FOR PAYROLL DEPARTMENT USE
OtSTRtfrJTtON
ATROLL NUMtfft
OCP d.E e COM
CY-RI 006974
Vi.j "3?
0mamMJU*ny
CYANAMIO EMPLOYEES SAVINGS PLAN ENROLLMENT FORM
Plif Prints NAME
RAOROERSBENSST
EP BC -r .
STACCT
near ,1 ` , .
CtT*
1
DEFF EE min*w T *'Tf
.1 1 1 111 1 1 tie COOK
GHDP
o p e ir t m
OP TCOP e mp l o y me n t
<o Dtv. ::;x -
SML
. t .t rf
w r d l l **** 4ft JB*9( 4 TYRE
mm s.
ENROLLMENT OAT*
t.0/*f/77
-MO..
>.CAR
-s h a d e d a r e a t o b e c o mp l e t e d b y COMPANY--
To enroll in the Cyanamid Employees Savings Plan, this form must be completed and returned to your Personnel or Employee Benefits Department.
I authorize the Company and/or the Plan Trustee.to enroll me in the Cyanamid Employees Savings Plan, and thus:
A. Authorize a deduction from my pay amount ing to the following percentage of "earn ings": (Circle on)
2% 3% 4% /5%)
B. Invest my savings as indicated at the right:
Government Bond Fund. Fixed Income Fund Diversified Fund Company Stock Fund
_%
-%
(Any combination of multiples of 10% wflicn total 100%)
Unless I request otherwise, I understand that in theevent of my death before termination of my employment, the full value of my accounts will be used to purchase a full cash fefund annuity for my spouse if I am married at my death. Otherwise, the full value of my accounts will be paid in a lump sum to my estate.
(Check [ /] only one) l accept the above terms.
H l hereby request to have thefull value of my accounts paid in (ciraeonet 60. 120, 180, 240. 300, 360, equal monthly, irmalroenls to:
the full value of my accounts paid in a lump sum to:
siLunoww
aooncst
l understand that I may change this payment arrangement at any time prior to my death while still employed and that upon termination of my employment for any reason other than death, I will have to make a new election regarding payment of my accounts.
I have received a copy of theprospectus relating to this plan.
h
77
P , SIGNATURE
DATE
This form must be forwarded by the Personnel or Employee Benefits Department Representative to ensure receipt by the
Employees Savings Plan Supervisor, Wayne, New Jersey 07470, at least 10 days before the enrollment date on which you
wish to join the plan.
_____
_________ _______________________________________________________________
REVIEWED EV:
ASMOVIO AY CMPbOVtC* AAViMAA Aba* AwACAVIMA
errceTiYA P I or rt JP P * fowbMCT KP LP ;
/
PAYROLLi-
Deductions commence with pay period ending:
A* <*
CY-RI 006975
RECEIVED
SEP 131977
CYANAMID EMPLOYEES SAVINGS PLAN SUPERVISOR
CY-RI 006976
1
f* ?49*iC9$ *ty M 72
PAYROLL CHANGE AUTHORIZATION
HD*IfMl K9
AMER'CAN OftHAMlQ ZO
SCUNO MOCt 1 ,
fALTiOrfC NO
COmFPMN 4 ivtSlON
OPP QR OR C**Ct
3Lf COM irt P ST OR SECTION
.oc :cct j
.rcA*
A 6522
UNCTION cooi
ACC0-0C0
NAMl
CHICAGO
0299
ACT ICO
lifTH AT|
MF6.
097 l
1 COn T SfftvC! 5P ?I .OS 5*A*.<
B.B. ?*v*'Cs :* *
Cl 31
OR
R.L.JOHNSON
-o r t it l e
no SPU1R2* /1 7/36109/16/76 AC.Al 1A,A*V
SUFT
PLANT SOFT.
7
ho.
COMPLETE NEXT TWO ONES EQt NEW EMPLOYEE TRANSFER IETWf|N PAY POINTS. ANO IANT EMPLOYEE GOING f*C
0f AOOtfSS STRUT
SIR SOC SIC sc
AS IS
"A.iQ'ED 3*i*
::r
HOMl AOORISS-CTv 4 $TP T|
t yp* or EXPY GI
n><zip CODE MARt'AL n i-s
;>t| cou | esc 5 PVE :
59 i T | i
:-
tGRft WP aft 1^*6} COU r-sc
IGH n s 0'-f con i cue
3 4
US -O
1 1 1II1 1 , ft C*-ft
i' : i
Ch*ck onei comptaff opproprio** section or steftons btlo*.
1; ! 243
fj 3
|.
i 1 -
1
j
ZP[\ ]P ^ w o r k ed
CONTINUOUS KRvtCI DATE
TERMINATION
VACATION FAY OUt
WKS_P` in ueu or n o abEe
CIO
OAYS RICOMMCNOID FOR RfHIRE
MO. CONTROLLER'S 0* OTHER r eq u ir ed AUTNOPOATIOM
WKS.
OATS O'" tilln o
AUTHORIZE |T
*Em now
` Di RfPLACE. Pno tm.
or CMPLora w in g urucio
RltMAWIZA-ntW
pP qr sPtu w o r k e d
CP SOn HAVING iM
TERMINATION
Rg*$ON 0* t|MN*r*ON I (S'GN*no*'-uT?t* C*Ot^.Nt-v 7 r is iGcP dio n .#efgP h 3 OiSC"P RGI 'fftMINATlON-MUfUAi. 9ft iw*fioltrA*RTo rSfteVlTiiCjIkPlio n o* c* 7 UTiRCmCn T B SgAfM ft UNRATION or CONt vict CTS51*
O
orh a v e
auenc e
REINSTATE rROM llAVf or ARMNCI
IvP wxP TiOm SCALE 4 MGRCI
BUDGET REMARKS*
ON HAVE SINCE
UST OATC WORKED
n
VARIATION t o NEAREST POINT 9* RP yGI
*io* - PRRHQTIONAL
* - FRO-KATA MERIT
CY-RI 006977
DEPARTMENTAL ANO Dz{z|z}~P P NBOPSP OP
Rif 1PS
CONTROL GROUP
FOR PAYROLL DEPARTMENT USE
RAvROtl NUMOff
SB ***'0S5 N. it-TS
PAYROLL CHANG*
AUTHORIZATION
~ a/,c/,a
NEXT t hese LINES SHOULD SEFIECT EMPLOYEE'S STATUS AETES CHANGE IS MAOE 3/ O/ /O
fMRLOMf NO
6522
COMPANY 4 QW1VOM
ACCO-OCD
RIANT 0# OR**CI
CHICAGO
MR* COM Df*T ANO et SIC*'ON
02 99
P P Et u r in g
f u n c t io n COOf
CMRlOrff NAP*#
AC! MO
fitfw OATI
| CONT Sflvd 5*1
,0# COM
R.L. JOHNSON .0# mtt
12/17/36109/16/76
-.fvfi
PLANT ENGINEER
6
*MtRCAN CVANABA40 *0 tCUNO $ROO* s ;
.oc coot
097 !
.yr :n
B.B.
0#V4*.5 i
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ms7-lm.irr.,.r
AC'.A; JALA**
iHBR. MO.
V3iV
2L3 3
!
~C*C tf5**a s'l!ft -C**f OMIJS-CiTY 4 iT*Tf
T<H OP C*ANG
lit
Ztf COO*
n-
MARITAL 5*P Tu $ , 5
ml
SOC SIC so
MOM* AS IS
> :c:?
MG*M -* ..1
BS 5"9 iTV",` ::u i5;5;
61BA, M ' ! 5!Gtf **0 9M
s *sscc
?:js
* I'v**; cou rK i ii
P* ;^R*| COU J 3*SC
!1
; 0*"*
OttcJt and complete oppropnoft action or sections below.
i
P P WORRIO
E t in u o u s scivtei P *
t ek m P io n
VACATION RAY QM
WKS RAY IN UCU OR NOnC*
MO. C0NT0ilirS 0* OTMCt QUWCft AUTHORUAtlOM
*$
MO
DAYS OATS
KCOMMtNfitP Ot HWff
n n-
AUTHOMIOtr P P * OR CMRtORR tflNO RtfUOO
* Di - Aoomo* WUCt. P . mn.
P
s___
U$T DAT! WOMID
MASON HAVING lO*
*TfRMIMATtOM
RfA$0N <0* T|RMIMA?IN
> tfStfiNAT'N-#fT*S* 0**ORTw*(*' ? f$lGNAriON*($CNAl 3 0*SCA#Gt TftMINATlON-MjTUAl j lArO OR !Un . P *.Cn 0* JO# A MU-TAR* MRviCI 7. I9 OMINP TAmnoN a* E * siRv cg ::
' '
LEAVE OF ABSENCE
RtMSTATf **
l!AVf OR AlSCMC!
{P P
SCAU 4 Ofone
REMARKS'
OMOAVfSMCf
LAST 0Af| w OMIO
1
n
VARIATION TO NCMIST *0***T O* RP GI
MIN. PLUS $202
MrunMMTU 4N0 ONWOMU MMOVUl AMD 0*111
. fn ii oirf
llh^L+Jk*
TST*0*1* ,xl
CONTROL OROUR
c/
FOR PAYROLL DEPARTMENT USE
0*STtl#UTlON
PAYROLL MUMit*
LOCATION COOf
0Nt0uf s fc**oA. 1 :*;
CY-RI 006978
j MfNC! ;oc* ;
1
?
ouo
174*10*9 Rw f M 7?
PAYROLL CHANGf
^ 5A*f
AMHKAN t'* ANAMlO CO
IOUNO *00 N ;
AUTHORIZATION'
NEXT THREE LINES SHOULD REFLECT EMPLOYEE'S STATUS AFTER CHANGE *S MAQg
(M#LOV(| NO.
tCOMPANY OIV1SOW
PLANT OR 0PP*a
m*t coot
:i P : E sir >
=:* 3'v
;5I E '
oS22
En coot
EICU
ACCU-UCD
CHICAGO
(FAPLOTH NAMK k L JLHAiSL'N
u29S
MANuFAC TIMING .
097; SooHD bRUUi
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i nr* :P *i
j
1 12-17-361
s j p v 'Cj :*?
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7- i FT09-16-71 bJTL
Cs L*** $
243 3
JO* coot
j o * mu
ifVfl
; JAVAR* AMQf_________________________________
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j
EPL1
ML ANT cNtiK
JMHHl
mo
COMPUTE NEXT TWO LINES POP NEW EMPLOYEE TRANSFER BETWEEN PAY POINTS "
h o n Pr }>$;k it
H* soc st: **:
wsrSwso f r o m*
:*o>!* P is
; ! :su j 5 sc
r"5~A"-S I
-OP ADORtW-Cirr t STATf *TPf OP C P *
fMKTlvf CAT!
m;:r
MA#!*AL S*P ^S , . 5
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5$ ! I : s :- i
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Chtek and eompltn opproprro't taction or ttcrions S/ow.
I
n s w e mp io v e e
*(K3 COnm HLOWI
COnMNT ANC OIVISIO**
jpay
C ;C!
* H'<*( ;a$* :*** <i:
TKAHSm
.AiiO COMMn wo*
MT AMO OR 9ICT10M
AYRQu .OC4TICM
3 s au r y c h an g e
10--01--77
PERF. POT.
pr esent sal ar y c h ang e
RATING_____
_Oi.
Ml
LAST SALARY CHANGE
MUltl
STATUS CHANOi
4RtCUSftHCAnON ____NiO CO-NTH Ni0w'
LAST P WORK
00-00-00
CONTINUOUS SIRVlCI OAT!
TERMINATION
P E Pt io n PAT out
WRS.
P in imu o p Nona
MO.
coMTRouors ot ONI acQuan PP
wl
ISO
OATS
OP
KC0mm(n 0CD OR *f-iRf
AUTHOR**
P E o p tMPLC-rtf ttiMo E PE
t AOomoN
` Di RPCP,tArOi.k .
LAST OATS WORRID
f ASON 4AV1NC :OS
TfRAMNATlON
*00- m_ MQ ra
{X|mp*iOn COM
JZLaCXCMPT MIMPT tlASON OA 1*A-MN4ttN
1 WSiONttlC^it^H 0**C**UMiTY 2 *IStOMAT;OM-N*SOMA4 3. OiSCHAROt 4 *f*MlNAr*CM.MUrUAL AO*fiCNt 5*7 *-lA!uT*i0u*Mr*r|N0s*TfRfitvMtcIMi ATlOM QP >01 I MATH ilMADON OP CON* Sdvci CRCOlT
j
LEAVE OF ASS!NCI
RfIMSTATt PROM LlAVf OP AlSfNCt
(VALUATION SCAif A OfORM
REMARKS:
ON LlAVf KNCI
P $T 3P T| w o r k
nn
VARIATION TO IRAHS: POINT OP (AMCC
MIN + 142
ll / / ^
P*"Jij*TAI AMO 0*V*SION4U APPROVALS ANO OAff| n
H________________________ ___
^ACH^NOATI * /flu
CONTROL OROUR
PAYROLL NUMRfR
.OCP *<Qn E E9I
CY-RI006979
!S.3{nC! :55t
M.749.I09S4M It TJ
PAYROLL CHANOl
9*n
*Pf*AitD
AUTHORIZATION*
_ c,
NgXT THRtt NtS SHOULD ftCFUCT gMFlQYH*S STATUS AfTH CHANGE IS MAQt
1
EMPLOYEE NO.
6522
COMPANY A OwtHON
ACC0-0C0
PLANT OR OPPl
CHICAGO
OCPT COM MPT AND OR SEC* Cs
0299
MFG.
f u n E t io n COM
El 00
iQ* E
EPLT
EMPLOYEE MINI
R.L.JOHNSON
>0# TtTiE
PLANT ENGINEER
P C! ffO
1-2
LEVEL
6
WN o P
12/1 7/36
SALARY A**OC
i4MttA* CYANAP CO
IOUNO MOO* N
COM i
.CC*'"On
097 ! B.B.
:>t s{i.'c; ;i*i
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?J'**'Cn
09/16/76 --r- >ifv f"4" .#**
| 1 ; ; *mA ! ! 1 t
?Y*vP
j A"v*. :*.**
:.v USE CM*
243
3
NOME AOORCSS-STtin
4044 N. KOLMAR
*0*4 AAMESS-CITY A STATE
CHICAGO,
TYPf O' CHANOl
ILL.
v NfW EMPLOYEE
01 4^ocoM^n<MLO<n
09/16/76
TRANSFER
*oo eoMPim * mix
ZIP COM 60641
SEX soc si : h o
DECREE P S IS
: * !;S
m;:r
MARITAL
ezl Li
DEGREE P ..
iTWfj -COIL j 5-SC T iSOC 5911 :465; 08
DECREE NO OTMfR
3 ..1
> Zd
" nfer
rt ;..! :su. ; esc
11 1l
1 1
;-"j cou ! e.sc
Ii
i
i r.ii
Chock and compitio appropriate toction or sections bc/ow,
COMPANY AMO OlVtStON
i .P s t ;*! #cno
Ss & PUNT OR CKI
01 1 o
OCPT AMO.'OR SECTION
PP y r o l l ;OCP ::Om
3 SAURY CHANG!
STATUS CHANGE
E E P s S E P io n
NJOCOMNTRARPtX
5 TERMINATION
00
AOOtnON
i: REPLACE. AOV WL
z
PERF. ROT. RATING_____
.... m.
PRESENT SALARY CHANGE
n
z
jotmii
LAST SAURY CHANGE
LEVEL COM
l tieZC
jn
| .UNCnOM SSO A*ROLL HO
11"1! 11 -ENXEEMXEPMT PT i
j-J
UST OAV WQRRCO
VACATIOM PAT out WKS.
P im utu o p Nona
CONTINUOUS SfRVICC 0AT|
RECOMMENDED PQR RfwRt ... n o
REASON FOR TERMINATION
21 R<CCSSIIOONNAATnlOONM..PMtfRT$CORNOAPlPORTUNITY 3 O'SC^AROt 4 TfRMINATION-MurjAl AG*EEmNT 5 LAYOFF OR Ur in P o p XI A Pr y EE 7 RETIREMENT
9 C3SXAPTtHAnON OP COMf. SERVICE CRtOiT
MO,__________WKS,__________ OATS
coMTtouars o r o t her v o u n s d PP
AUTHoaaott
HHH
7/76
MAMI OP EMPLOYEE KMO MPUOD
UST OAft WORKS
REASON ifAVIMO j o e
t e r m P io n
LEAVE of ASSCNCC
REINSTATE **Om lEAVf OP AlSINa
EVALUATION SCALE A OEORfl
UOOiT
REMARKSt
ONiiAVtSiKt
LAST OATf WORKED
WITH
n A*
n
VARIATION TO Pr e s t p o in t o p P
a"~
PfKSRiU mW. APPROVAL A DATE
CY-RI 006980
CONTROLLER $ APPROVAL | 3A5
CONTROL OROUP
Wit,
FOR PAYRQU DEPARTMENT USE
MTtMWnON
PAYROLL NUMAW
E P t io n COM
RESOfNC! :C9C
ii
(Please Print) NAME 0!; IMPI.OVKR
1 fa Payroll Dcpaiimctu
This it to confirm that employee and employer have agreed as follows:
l. Effective with the payroll period honinniuB
., the employer it hereby authorized
to wirhhald fiom the employee's
payroll period Federal Income la*, In addition to that re
quired by law, in the amount of___Dollars. Additional withholding will he made only in amounts set forth in the table below.
Ibis agreement tr iv hr terminated by cithrt the employee or the implo>..t elietiive with res; ert to any no period by gr. >ng written notice to the other of such termination at least thirty f 10) du\ prior to the beginning of such pnv period.
3. No refunds will be made by the employer to the employee of any additional amounts withheld under this agreement.
4. If the amount of pay due for nnv pny period is insufficient to meet all paytoll deductions, there will be no withholding under this agreement for such period, and such omitted withholding will not hr made up in subsequent payroll periods.
DATE Q3-fT-
Y fUtft
Signature of Emp
Authorized Signature
(l)
I'r.u Vvt rode
A B C D E F r. H i
J
K L
C)
Additional
0<,lui(nin
tP 10 14 20 24 10 14 44 40 70 90
110
i\\
h>( ,il
\i i i iu .i I
|) .h. i*tf
i iro 2-10 >,i.O ISO OIK) '.'tl SI0
1,1180 1. .'.*)(* l.t.SO 2.U.0 2.640
In the c\em employee uishc* an aci.liiuHt.ii
numthlv.Utiuytiointi i vi".-* #l ft
vi*m v i
H, Uuenswh on I
tyyt,
HA Ot
4.T3 *3* *,)
S-P-rU*n'*J 38n j J.
it 'i
l; my
1 Vp.tnuu nt
Kmployi'f No,
CY RI 006981
