ContraCt amendment University of California Staff and academic…

ContraCt amendment
University of California Staff and academic reduction in time (Start) 7/1/08­6/30/10
U271 (6/08)




PerSonaL InFormatIon
name                                                                                empLoYee numbeR                         soCiaL seCuRitY numbeR



DepaRtment                                                                          LoCation                                Campus pHone
                                                                                                                            (           )

paYRoLL titLe                                                                       pRe-staRt appointment peRCentaGe




I wish to amend my START contract dated _________________ and (check one below):

    end my participation in START effective: _________________

    change my START percentage of time to: _________________% of full-time, effective _________________.

My revised START work schedule will be:

 Days
 Hours


eLeCtIon
empLoYee siGnatuRe                                       Date                      DepaRtment HeaD siGnatuRe                                Date




                                                                 PRIVACY NOTIFICATIONS
STATE
the state of California information practices act of 1977 (effective July 1, 1978) requires the university to provide the following informa-
tion to individuals who are asked to supply information about themselves.
the principal purpose for requesting information on this form, including your social security number, is to verify your identity, and/or for
benefits administration, and/or for federal and state income tax reporting. university policy and state and federal statutes authorize the
maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent
completion of the action for which the form is being filled out. information furnished on this form may be transmitted to the federal and
state governments when required by law.
individuals have the right to review their own records in accordance with university personnel policy and collective bargaining agree-
ments. information on applicable policies and agreements can be obtained from campus or office of the president staff and academic
personnel offices.
the official responsible for maintaining the information contained on this form is the associate Vice president--university of California
Human Resources and benefits, 1111 Franklin street, oakland, Ca 94607-5200.

FEDERAL
pursuant to the Federal privacy act of 1974, you are hereby notified that disclosure of your social security number is mandatory. the
university's record keeping system was established prior to January 1, 1975 under the authority of the Regents of the university of Cali-
fornia under article 1X, section 9 of the California Constitution. the principal uses of your social security number shall be for state tax
and federal income tax (under internal Revenue Code sections 6011.6051 and 6059) reporting, and/or for benefits administration, and/or
to verify your identity.


Retention: Home DepaRtment: 5 years after separation, except in cases of disability or retirement, in which case retain until age 70.
Copies to: 1) Local Human Resources or academic personnel office 2) Retirement administration at the office of the president, 300 Lakeside Dr.
5th Floor, oakland, Ca 94612-3550 and 3) employee