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It: ' i \

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ijSlmplcx NO. NAME IkAv. PAYPERIO''''i?flyg>

ru Se.a fi'-.6 This side for REGULAR TIME only

Use other side for overtime

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PAY PERIOD ENDING

I Ilr /f9 NAME l. suz,l\ets

This side for REGULAR TIME only Use other side for overtime

1:;'

Dally Totals I R.T. H" .. n", • " ••• n" .. n'" Tn JIll ... I .. n" """ la Dally Totals R.T. HOURS J,O.T. HOURS ;= p400 R.T. Hours O.T.

:;: n RATE' t n711 Total Earnings E n7zo

EP359 ;=n7Z9

FED.W.T.-

crrYlST. W.T.

TATEU.C.-

BONDS-

Total Oeducllons

"

BALANCEOUE /'

.. , ,-

TOTAL HOURS SHOWN IS CORRECT. Signature 1950-9201 SIMPlEX TIME RECORDER CO .. GARDNER. MA 1-80Q.626-6206

" ,,--

:

3, ,:; -,>' f • '.;

L n7zz R.T. Houra O.T,

ij L P358 J----j E

';= 0757 II '--..,;= p40z r, , :;: n 133

1 \. , :;: p400

E 0726 E p400 L1l1z6

Total Earnings

NO. OF EXEMPTIONS

i--MEDI.-

t-FED. W.T.-

crrYlST. W.T.

t-srATE U.c.-

I-BONDS-

Tota' Deductions

BALANCEOUE

TOTAL HOURS SHOWN IS CORRECT. Signature 1950-9201 SIMPLEX TIME RECORDER CO •• GARDNER. MA 1-80D-626-6206

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I

MPIA 15 459 696

(.f lLLEGE OR UNIVERSITY

OP? IN S TA r E SOCIAL

R 7 TO 12

1:1 TO 18 19 TO 24

'2S1030 11 TO 36

':17T042 7-7110 i ,111048 8-8.'10

1<110549-910 :"ST060 0-lHR

LEAVE CODES 1 ;'n Annual ,', Anl1uaf-Arlv IRO

'R, Swk:-Arlnrftor'l 'R) Swil.·Af'rp;:tvprnent , ;::; . -SIck -Arfyano?lj lR,1 S'rl<-E)(fenrjf"d

A("(!rlpnt ll>a\'fl

Swl<.·Frtmdy 011 Hnl!>1av

11)0 Pf>rsonal

170 UnpaId lE"3Vf>

no Mdltary .1-111 Jury Doty

Arlmm f'(;:Jm IrJterview

·1;'"0 Comp Earned ,-, RAA

012

Leave Used This Year

[CK 1 9.00 14.87 )LIDAY 0.00 10.00

4.00 3.00 )"P HOURS USE OR LOSE lIS PAY 2 WKS 4

NAME

Sh,ltCode

y

TITLE

MAINT AIDE I

26·Pay Hrs. Used

119.00 0

PERSONNEL COpy

TIME SHEE-' )

.....

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-""""

---'

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MPIA 15 459 699

I' .. ' '," '1' I' ", ," ":.; 't ..nll; .. ",t, ,,1 ' , ' " I:, ,',J,,': ; f},', ',:,

!.tSJrnpJex NO.

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" ? 1 It! ",,' Ii, ,,1, ,'" ,h, l;\, i tii d;", J ',i,',"". ,

PAYPE.ODE"'i / Jb

L"C

this side for REGULAR TIME only Use other side for overtime

3 "'·"-'1 .. nOURS O.T.HOURS L P 59 R.T.HouraO.T.

:3 A7zz Ii' 3P403 AMyNT

Total earnIngs

11111111

Dally Totals R.T. HOURS f\tO.T. HOURS R.T. Hours O.T.

:3 n 130 RAE

:3 p351 e: n7zz .

Tolal Eamlngs l: 0'739 ' l: p401 fNO•OF

EXEMPllONS

S.SEC.-I 1111111 MEDL-

FED.W.T.-

e: 0730 I ClTYIST. W.T.

en7Z6 I--S.SEC.-

I ;= p400 r-MEDJ.-3 n1Z6 3p4oo f-FED. W.T.-

! e: 01Z6 CITYIST. W.T.

e: 0131 I t-srATE U.c.-e: 0731

e I (-msuRANCE"" e p400 I t-BONOS-307z9 3 p400 e: 07Z1 e: p400 I I Total Deductions

BALANCE DUE

\ e: p401 I I :=n7Z6 rsTATEU.C.-

l rwSURANCI:

I -BONDS-!

I Tolal Deductions

I I ! BALANCE DUE

TOTAL HOURS SHOWN IS CORRECT. SIgnature TOTAL HOURS SHOWN IS CORRECT. SIgnature

"', 1951).9201 SIMPLEX TIME 'RECORDER CO .. GARDNER, MA 1-800-626-6206 '"

1951).9201 SIMPLEX TIME RECORDER CO., GARDNER, MA 1-800-626-6206

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MPIA 15 459 697

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NO.

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h PAY ""';"J <r /91

NAME

, This side for REGULAR TIME only Use other side for overtime,

e: p40z L 07Z9"

;: 0735 ;: 07Z3 ;: p400 e: 0729 e: 3 A7Zl .. 3P359 ;: 0728 e: R 718 e: P358 LA1z1

Dally Tolal. I R.T. HOURS 'I O.T. HOURS ,R.T. Hour. O.T. -,-,-RTE

t---AMr lfr

Tolal Earnings

'NO,OF EXEMPTIONS

f-S.SEc.-

i--MEDI.-

f-FED.W.T.-

CfTY/sT.W.T.

r-s-rATE U.C.-

hNSURANCe-

r-BONDS-'-

Total Deducllons

BALANCE DUE

TOTAL HOURS SHOWN IS CORRECT. Signature 1850-8201 SIMPLEX nME RECORDER CO., GARDNER. MA 1-8()().62H206

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MPIA 15 459 698

PERSONNEL PAYROLL CHANGE FORM

SOCIAL SECURITY #: 213-76-1224

NAME: Alonzo Sellers

CLASSIFICATION: Maintenance Aide I

PROGRAM: 7 FUND: 1 PROGRAM CHANGE:

PRESENT SALARY: 21,362

EFFECTIVE DATE: 01-01-99

PERSONNEL ACTION: COLA

DEPARTMENT: Facilities

COMMENTS:

(Signature)

NEW SALARY: 21,737

CHARGE CODE:

PIN: 041461

FUND CHANGE:

(Date)

MPIA 15 459 754

--- 1999 ,'-\etropoiitan life Insurance Enrollment Form -- PART K , Conltnued - PERSONAL DATA FOR LIFE INSURANCE IL.lIlIl.'!I -- Name: SELLERS .. .. --4 4

,5 5

16

• I 7 7.

I :', : ' 9' 99, ,9

ALOIIZO ..

4:' I m:::!) m:m G) l:!) (I::(§) (§) ill

If: .v c.c:' if· (§) nD . .[ 'Lie j),m CihJ.)

" {(:;:,L @:(I) ,.:{; <L

- I have read the announcement describing the Contributory Group Life Insurance Program and indicate my coverage selection(s) below. -_ IF YOU CHOOSE AN AMOUNT GREATER THAN $50,000 FOR EMPLOYEE AND GREATER THAN $25,000 FOR SPOUSE OR CHILDREN, A STATE-_ MENT OF HEALTH MUST FIRST BE SUBMmED AND APPROVED BY THE LIFE INSURANCE CARRIER BEFORE THE POLICY WILL BE IN EFFECT. - SECTION 1: EMPLOYEE INSURANCE [":]'1)":'" -- Mark One Option: - Yes, I want to enroll as a new enrollee in Life - Insurance. Make a $ selection at right. -- Yes, I am currently enrolled and making a change. - Make a $ selection at right. -- No, I do not want to start this benefit. -- Cancel Life Insurance .. .. --

o $ 10,000 C $ 20,000 0 $ 30,000 0 $ 40,000 0 $ 50,000

STOP - If you choose a greater amount than $50,000, you must fill out a Ufe Insurance Statement of Health for yourself. 0$60,000 0 $110,000 0$70,000 C $120,000 o $ 80,000 0 $130,000 o $ 90,000 0 $140,000 o $100,000 0 $150,000

0$160,000 0$170,000 0$180,000 0$190,000 0$200,000

0$210,000 0$220,000 0$230,000 0$240,000 0$250,000

0$260,000 C $270,000 C $280,000 0$290,000 C $300,000

- SECTION 2: SPOUSE INSURANCE - NOTE: You cannot enroll your family members unless you, the employee, are enrolled. You cannot select an amount for your dependents greater - than 50% of the amount selected for yourself. = Mark One Option: - I currently have life insurance As of 1/1/99 0 $5,000 0$10,000 0$15,000 0$20,000 0$25,000 - on my spouse and am making - a change. Make a $ selection. -- Having selected life insurance for - myself, I wish to have life insurance - on my spouse. Make a $ selection. ---------

No, I do not want to start life insurance on my spouse.

Cancel life insurance on spouse.

(I) Cr:-(§)OC \.VT

9,9\

STOP - If you choose a greater amount than $25,000, you must fill out a Ufe Insurance Statement of Health for your spouse. o $ 30,000 0 $ 55,000 0 $ 80,000 o $ 35,000 0 $ 60,000 0 $ 85,000 o $ 40,000 0 $ 65,000 0 $ 90,000 o $ 45,000 0 $ 70,000 0 $ 95,000 o $ 50,000 0 $ 75,000 $100,000

0$105,000 0$110,000 0$115,000 0$120,000

$125,000

0$130,000 0$135,000 0$140,000 c.:: $145,000 c: $150,000

- SECTION 3: CHILDREN INSURANCE ICIIiII!i -- Mark One Option: - I currently have life insurance - on my child(ren) and am making - a change. Make a $ selection. -- Having selected life insurance for

myself, I wish to have life insurance r on my child(ren). Make a $ selection.

- No, I do not want to start life insurance - on my child(ren). -- Cancel life insurance on child(ren). ----

0$5,000 .= $10,000 0$15,000 := $20,000 $25,000

STOP If you choose a greater amount than $25,000, you must fill out a Ufe Insurance Statement of Health for each covered child.

$ 30,000 $ 55,000 $ 80,000 . $105,000 $130,000 $ 35,000 $ 60,000 $ 85,000 $110,000 $135,000 $40,000 $ 65,000 $ 90,000 :_ $115,000 $140,000 $45,000 $ 70,000 $95,000 .-:: $120,000 $145,000

.' $ 50,000 $ 75,000 , $100,000 '" $125,000 $150,000

MPIA 15 459 755

PART D PRESCRIPTION DRUG PLAN A -=---_ NOTE: Prescription Drug is NOT _ included in any health pTan. You

must be enrolled in the - Prescription Drug Plan if you - want this benefit. -

Choose One Option •. , New enrollment ------.- --

2 Addition or removal of a dependent 3,. No, I do not want to start this benefit 4 Cancel all current coverage

__ -If you marked number 1 or 2, mark one coverage level: Individual only • Individual plus spouse Individual plus one child; Individual plus two or more specify: _____ _ -/

r RT E DENTAL PLAN AP UNITED CONCORDIA DENTAL PLANS IIC..JIla

.. . .OTE: If you belong to an HMO _ or POS Plan you have dental

Choose One Option 1 .= Newenrollment--·--·· 2 \.") Addition or removal of a dependent

to_Choose One Plan . Dental Maintenance

Organization-OMO OR

Choose One Coverage Level =. Individual only

coverage. Part E UNITED - CONCORDIA DENTAL PlANS are - separate plans which require an 3 No, I do not want to start this benefit

Individual plus one child; specify: .,......,. ___ _

,_ Individual plus spouse _ additional deduction. This section _ is not for your dental coverage

4 C: Cancel all current coverage . Dental Point-of-Service (POS) Plan C:':; Individual plus two or more people

under an HMO or POS plan.

Choose One Option _If you marked number 1 or 2, mark one coverage level: 1 '_' New enrollment .. -------.. --. .,..... -:-.) Individual only'= Individual plus spouse

Addition or removal of a dependent C: Individual plus one child; •. Individual plus two or more --- 3 No, I do not want to start this benefit specify: _____ _

4 C Cancel all current coverage ----PART G PRE-TAX SPENDING ACCOUNTS HEALTH CARE AND/OR DEPENDENT CARE ilfLk.,

_ YOU MUST COMPLETE PART G IF YOU WANT A SPENDING ACCOUNT IN 1999. _ I want to set aside the following amounts in spending accounts -_ my deduction per paycheck (biweekly (24 pays), monthly (12 pays) or 21-pay faculty(19 pays)) (in dollars and cents): _ THIS IS A PRE-TAX BENEFIT AND FUNDS MUST BE WITHDRAWN BY 411512000. _ .'\K--=' Enroll in Health Care Spending Account AN 0 Enroll in De endent Care Spending Account ------------.,

,{j ,::!) 5 $ ..

iJ.J lsI) 9 '9:' '"Ii

Write in dollar amount per paycheck

REMINDER: This is nota yearly deduction amount. This is

&. the amount to be jij CQ:' deducted per (1.:. paycheckin (8: 1999. iJ:' 19:'

'.:) Cancel Health Care Spending Account

Write in dollar amount per paycheck

REMINDER: This is not a yearly deduction amount. This is the amount to be deducted per paycheck in 1999 for daycare or child care expenses for children under 13.

o Cancel Dependent Care Spending Account

-

.. -- PART H PERSONAL ACCIDENT & DISMEMBERMENT (American Home Assurance Company) (AV) - Mark One Option: - 1 New enrollment-make a $ selection·-----_ 2 r'. Change of benefit amount-make a $ selection'-_..i No, I do not want to start this benefit

- .j Cancel all current coverage -

If you marked option 1 or 2, mark one coverage level: o Employee only coverage o Family coverage

Choose one benefit amount: 0$100,000

$200,000 0$300,000

-- PART I EMPLOYEE SIGNATURE - Please enroll me for the Flexible Benefits indicated on this form. I understand the benefits and limitations provided by the various plans, and I authorize the State of _ Maryland to make the necessary adjustments in my pay based on the choices I have made. To the extent deemed necessary by the Plan Administrator for the proper _ administration of my coverages, I authorize the release of all medical records and related information pertaining to me or to my dependents. The personal information _ provided on this enrollment form is warranted to be complete, accurate, and in accordance with Department of Budget and Management regulations. I understand that

I cannot cancel or change my enrollment except during an Open Enrollment period or as the result of a change in family status permitted by Section 125 of the Internal - Revenue Code. - I understand that if I have enrolled in one or both of the Pre, tax Spending Accounts, that I must file for reimbursement from :nose accounts by April 15. 2000 in order _ to avoid losing my contributions, that if any deduction is not taken that I must immediately forward my personal check for the amount of the missed contribution to the _ DBM Employee Benefits Division, and that my decision to deposit funds in the Spending Accounts is binding through December 31, 1999 and can only be mcdifierj if _ there is a qualifying change in family status as outlined in the Benefits Cost and Comparisons booklet.

I I understand that the Flexible Benefits Program offered by the State is subject to modifications and changes and that the benefits I have chosen in this enrollment - , 'arm are only in effect for calendar year 1999. The State of Maryland reserves the right to modify any of the benefits provided and gives no assurances, express or -I' implied, that any coverage obtained hereunder will continue beyond calendar year 1999. I certify that neither I nor my family members are covered under another State - of Maryland employee's or retiree's membership. - I UNDERSTAND THAT ENROLLMENT IN BENEFITS TO WHICH I OR MY DEPENDENTS ARE NOT ENTITLED IS CONSIDERED FRAUD. IN ALL CASES I AM RESPONSIBLE FCR THE ACCURACY _ OF MY BENEFITS. COVERAGE LEVELS AND DEDUCTIONS. I FURTHER UNDERSTAND THAT IF I WILLFULLY MISREPRESENT THE ELIGIBILITY OF MYSELF OR MY DEPENDENTS ON MY HEALTH • BENEFITS APPLICATION. OR FAIL TO TAKE THE NECESSARY ACTION TO REMOVE INELIGIBLE DEPENDENTS, OR IN ANY WAY OBTAIN BENEFITS TO WHICH I AM NOT ENTITLEO-MY

BENEFITS WILL BE CANCELLED. I MAY BE REQUIRED TO REPAY ANY CLAIMS WHICH HAVE BEEN PAID INAPPROPRIATELY, AND I MAY FACE CHARGES FOR DISMISSAL FROM STATE SERVICE. • NOTE: H you have any questions concerning the benefits and services that are provided by or excluded under this agreement, please contact a member service representative before signing this application. • •

• Is there any other health insurance coverage in which you, your spouse or any of your dependents are enrolled? C.' Yes- No • • •

Specify Who is Covered, Name of Insurance Company and Policy Number: ___________________________ _

/ ! our Signature Date Your Home Phone Number Your Work Phone Number .. .

• • PART J AGENCY SIGNATURE - Agency Must Sign Here -=:JIIIiI

• I hereby certify that the person applying for enrollment hereon is employed by the Agency.

• / / • X • --;:---:-=:_:_7:"-:-------------------- Date Work Phone Number (Ext.) Department _____________________________________ ______________ __ ________ --J

MPIA 15 459 756

'>tall' 01 \\<Hyl.1nd - Oep.lrtment ot Budget and ,\ianagement Active and Satellite Employees Enrollment Form for 1999 Benefits

Right Mark. Wrong Marks V r..,.-L ___ A

---fWIT A PERSONAL DATA -=- -Name: SELLERS ALONZO N Address: 6505 SILIIORE ST

Il00DLAIIH lID 21207

Nark Phone No.: _,t ___ _ Home Phone No.: .J _ .. __ . ________________ _ County of Residence: _____ . _______________ , ___ , _____ . __ _

Fan 1998 Open Enrollment Only The coverage listed below will continue into 1999 unless you make a change during Open Enrollment. You must complete Part G if you want a Spending Account in 1999.

Prescription Drug: YES UDIVIDUAL Dental: NO Vision: YES INDIVIDUAL

YES BCBSK BLUE PLUS POS

i-i-, I-i_ i ,-i-I-i-

INDIVIDUAL ' -Pay Center: CENTRAL PAYROLL PA&D Insurance: NO ' -Pay Cycle: BI-IlEEKLY 21-Pay Faculty: NO Life Insurance: Employee· NO i-Date of Birth: 11/01/58 Sex: II ;-

I work full-time or or more of the normal week:

Yes No

Pay Center: c Central Payroll u University of MD s Satellite (specify):

I am paid: B Biweekly M C) Monthly

I am 21-Pay Faculty: ' ..... ) Yes l_, No

Sex: Marital Status: M r') Male S '-::. Single

_ Female M Married L Separated

Divorced w Widowed

,-i_ I

\-i--I work ___ hrs. per week ____

New Employee. Entry on duty date: Return from leave of absence. Date:----------Employee requesting change due to change in family status

less than

enrollment status Change in family status (status 3 above)

A Add spouse or dependent because of: Marriage. Date:

" Birth! Adoption! Ap-po-'--in-;-ted--'-'l-eg-a1"7guardian. Date: _____ _ -', Resume student status. Date:

, Other: ___ B Remove spouse or dependent because of:

Divorce/Legal separation. Date: ____ ..--;--Death of: Date: __ _ Dependent not eligible-List in Part C below.

c Other Change: __ -:-__ -;;-:-:-7"-;--,--__ -;;-;-______ _

- Cancel all coverage-no longer eligible for benefits

360227

,3 3 ,:4. 4

6' 6

-----1:_ 2'_ J :_ 4:_ i_

I 6'_ 7;_ e--PART B MEDICAL PLAN (SELECT ONE PLAN ONLy). Out-ot-State Residents (beyond 25 miles) may choose BCBSM PPO QNI,.'y. -=- -Choose One Option

New Enrollment or Change of Plan Addition or removal of a dependent No, I do not want to start this benefit

If you marked number 1 or 2, mark one coverage level: '_ ,"- Individual only For DBM use only -

Individual plus one child; specify: 5) ':6". "z" , 8 9 1 0 : ' -Individual plus spouse-Individual plus two or more -

__ End Stage Renal Disease (ESRD) (Must have Medicare A & B)-'-Cancel all current medical Ian covera e indicate below which Ian OU are cancellin ) If you or a dependent have Medicare, write in name, Medicare number, ,effective date of Medicare and coverage level.

II " ---------------------------------------------------------------L-__ .. Fill in ONE oval ONLY for your medical plan: --I UNDERSTAND THAT IF I LIVE OUT OF THE STATE OF MARYLAND (BY MORE THAN 25 MILES) I MUST ENROLL IN BCBSM PPO PLAN ONLY. -In-State HMO Plans- --Out-of-State In-State PPO Plans In-State POS Plans Check with HMO plan to

PPO Plan OR Available by Region OR Available in All Regions OR confirm if it serves your area.

BCBSM PPO X422

No dental coverage included under PPO

Region 1-BCBSM PPO C422 Region 2-MLH Eagle PPO S492

" Region 3-MLH Eagle PPO E492 Region 4-MLH Eagle PPO W492 No dental coverage included under PPO

Prescription Drug coverage not included in any medical plan

BCBSM-Blue Plus POS 581 M.D. IPA Preferred POS 531 NYL Care POS 651

Dental coverage is included under POS and HMO plans

-Freestate HMO 470 -George Washington University HMO 270 -

.-/ Kaiser HMO 560 -NYL Care HMO 570 -Optimum Choice, Inc. HMO 640 -Prudential HMO 370 -United Healthcare (Chesapeake) HMO 460 -

PART C DEPENDENT INFORMATION PLEASE PRINT CLEARLY -=- --THE FOLLOWING IS RESERVED FOR DEPENDENT INFORMATION. PLEASE MAKE ANY CHANGES TO YOUR DEPENDENT FILE BELOW. YOU MAY _ USE THIS SECTION FOR ADDITIONS (A), DELETIONS (D), OR CHANGES (C) TO YOUR EXISTING HEALTH BENEFITS FILE. (NEW EMPLOYEES _ COMPLETE THIS SECTION IN FULL FOR YOUR DEPENDENTS.) _ PLEASE PRINT. DO NOT TYPE. COMPLETE ALL INFORMATION IF AN ENTRY IS MADE. DRAW A LINE FROM THE A1C/D BUBBLE TO THE NAME. * ,_

rnfl,j'll !Jhi:,,' ' I jlj§,i:'·j' j ,(MMPD_:!!; u' •• i C D I I -

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---------,..ha,.." if flilLti",o nUAr !lnA 1Q nr aver ace 19 (DSt -MPIA 15 459 757

11..010) NOUOIC SELLERS 6505 GIUIOAE 1M: Bll..TDd£ IIA III 21207

1111111111111111111111111111111111

,..... .. -- - -_ ...

• II I I,'

THIS NUM.EII HAS II!EN eSTABLisHeD FOil

ALONlO NOVOKSELLERS

, .i

I .

MPIA 15 459 694