Full-Time Paperwork

Employee Emergency Contact Form
Employee Name*

First NameMiddle NameLast Name
Former Name
Maiden Name
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Optional (the following information is optional and will not be used in a discriminatory manner)
Date of Birth

MonthDayYear
Date
Birthplace
Birth Country
Veteran (Y/N)
Marital Status
Race
Emergency Contact Information
Primary Contact Name
Relationship
Emergency Contact's Physical Address (will be kept confidential)

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
Signature*

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Date*

MonthDayYear
Date

W-4: Employee's Withholding Certificate
First name and middle initial*
Last name*
Social security number*
Address*
City or town, state, and ZIP code*
Filing Status*

Single or Married Filing SeparatelyMarried Filing Jointly or Qualifying Surviving SpouseHead of Household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual)
Multiple Jobs (only mark if applies)

If you have two jobs total, you may check this box. Do the same on Form W-4 for the other job.
Claim Dependent and Other Credits

(If your total income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000:
Multiply the number of dependents by $500:
Add the amounts above for qualifying children and other dependents and enter below. If you have no dependents or qualifying children, enter 0. *
Extra Withholding (enter any additional tax you want withheld each pay period)
Additional Information:

If you have any additional information or questions concerning the completion of the W-4 Certificate, please contact Human Resources.
Employee's signature (This form is not valid unless you sign it.)*

Clear
Date*

MonthDayYear
Date

NC-4: Employee's Withholding Allowance Certificate
First Name (USE CAPITAL LETTERS FOR YOUR NAME AND ADDRESS)*
Middle Initial*
Last Name*
Address*

Address

Street Address Line 2

CityState

Zip CodeCounty (Enter frat de lettera)
County (Enter first five Letters)*
Country (if not U.S.)
Social Security Number: First 3 Numbers* - Next 2 Numbers*- Last 4 Numbers*
Filing Status*

Single or Married Filing SeparatelyHead of HouseholdMarried Filing Jointly or Surviving Spouse
Total Number of allowances you are claiming: *
Additional Amount, if any withheld from each pay period (enter whole dollars)
Employee's Signature*

Clear
Date*

MonthDayYear
Date

Direct Deposit Authorization

In addition to this document, you must also submit in-person, a voided check or a direct deposit form from your bank.
Name*
Phone#*
Email Address
example@example.com
Bank/Credit Union Name
Bank Address

Address

Street Address Line 2

CityState

Postal / Zip Code
Bank/Credit Union Routing#
Checking Account#
I hereby authorize McDowell County to process payroll transactions through direct deposit and I also authorize McDowell County to Initiate adjusting entries which are necessary for corrections relating to payroll to the above named banking Institutions. This is a mandatory requirement for county employment.
Signature*

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Date*

MonthDayYear
Date

McDowell County Policies

Please read each thoroughly, sign and date.
Family and Medical Leave

In accordance with the Family and Medical Leave Act (“FMLA”), The County shall grant each eligible employee leave entitlements consistent with the provisions outlined in the FMLA. The terms used in this Section which are defined in the Act shall have the meanings assigned to them in the Act.

Eligibility: To be eligible for FMLA leave, the employee must:

a) Have been employed by The County for at least 12 months; and

b) Have worked at least 1,250 hours during the 12-month period immediately

preceding the commencement of the leave.

Under the FMLA, The County provides up to twelve (12) weeks of unpaid, job protected leave during any twelve (12) month period to eligible employees for the following reasons:

a) For incapacity due to pregnancy, prenatal medical care or child birth;

b) For the birth of, and to care for, the employee’s child after birth;

c) For placement of a child with employee for adoption or for foster care;

d) To care for the employee’s spouse, son or daughter (under age 18 unless disabled), or parent, who has a serious health condition; or

e) For a serious health condition that makes the employee unable to perform the functions of their job.

These provisions apply equally to a father as well as to a mother and limited to a combined total of twelve weeks if both mother and father are County employees.

In certain circumstances, certain eligible employees may also be entitled to up to 26 weeks during the 12-month period of Military Family Leave to provide care for a spouse, son, daughter, parent or next of kin who is a military service member recovering from a serious illness or injury sustained in the line of active duty; or 12 weeks during the 12-month period for any qualifying exigency arising out of the fact that the spouse, son, daughter, or parent of the employee is on active duty, or has been notified of an impending call to active duty status, in support of a contingency operation. Please see the Finance Office for questions or more information related to this specific type of leave.

Requesting Leave: If leave is planned, the employee should give at least thirty-days’ notice of his or her intent to take leave under FMLA. In cases of leave for planned medical treatment, the employee is required to make a reasonable effort to schedule the treatment so as not to unduly disrupt the operations of his or her department.

If the need for leave is unplanned, an employee must notify the employer as soon as the need for the leave becomes known. The notice shall be sufficient to make the immediate supervisor aware that the employee needs FMLA-qualifying leave, and the anticipated timing and duration of the leave.

Definition of Serious Health Condition: A serious health condition is an illness, injury, impairment, or physical or mental condition that involves either an overnight stay in a medical care facility, or continuing treatment by a health care provider for a condition that either prevents the employee from performing the functions of the employee’s job, or prevents the qualified family member from participating in school or other daily activities.

Subject to certain conditions, the continuing treatment requirement may be met by a period of incapacity of more than 3 consecutive calendar days combined with at least two visits to a health care provider or one visit and a regimen of continuing treatment, or incapacity due to pregnancy, or incapacity due to a chronic condition. Other conditions may meet the definition of continuing treatment.

Use of Leave: An employee does not need to use this leave entitlement in one block. Leave can be taken intermittently or on a reduced leave schedule when medically necessary.

Employees must make reasonable efforts to schedule leave for planned medical treatment so as not to unduly disrupt the employer’s operations. Leave due to qualifying exigencies may also be taken on an intermittent basis Health Care Provider’s Certification for Medical Leave: When FMLA leave relates to an employee’s serious health condition, The County may require that the employee’s request be supported by a certification issued by the employee’s heath care provider consistent with the guidelines in the FMLA. Under certain circumstances,

The County may require recertification consistent with the FMLA.

Continuation of Benefits: When an employee is on leave under FMLA, the County will continue the employee’s health benefits during the leave period at the same level and under the same conditions as if the employee continued to work. If the employee chooses not to return to work for reasons other than a serious health condition, the County will require reimbursement of the amount paid for the employee’s health insurance premium during the FMLA period.

Any insurance payments and/or payroll deductions are the responsibility of the employee and the employee must continue to make such payments for continued coverage of that benefit during FMLA leave.

Returning to Work: The County may request a periodic report from the employee or certifying physician regarding the employee’s status with respect to returning to work.

These may be made by telephone, written correspondence or sent by fax. Prior to returning to work, each employee shall provide a fitness-for duty certification from the health care provider.

Failure to return to work, and/or failure to reasonably communicate with the County about the employee’s ability to return to work following the expiration of all job-protected FMLA leave may result in the employee’s unprotected absences being treated as a voluntary resignation of employment resulting in separation. It is therefore critically important to interactively communicate with the County regarding the employee’s anticipated return to work date and to discuss any additional reasonable accommodations that may be required for covered, eligible employees under the Americans with Disabilities Act.

If an employee fails to return to work after the employee's leave entitlement has been exhausted or expires, the County has the legal right to request reimbursement for the monthly health insurance premiums paid on behalf of the employee, unless the reason the employee does not return is due to:

(1) The continuation, recurrence, or onset of a serious health condition which would entitle the employee leave under FMLA; or (2) Other circumstances beyond the employee's control.

When an employee fails to return to work because of the continuation, recurrence, or onset of a serious health condition, the employee shall provide medical certification of the employee's or family member's serious health condition.
Print Name*
Signature*

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Date*

MonthDayYear
Date
Harassment Policy

McDowell County is committed to maintaining a work environment that is free of all forms of discrimination and harassment. Accordingly, any practice, activity or conduct that is defines as harassment herein will not be tolerated and will result in disciplinary action.

Harassment Defined

Harassment is verbal or physical conduct that demonstrates hostility or aversion toward and individual on the basis of race, color, religion, gender, national origin, age or disability, or other US Constitutional areas:

-Has the purpose or effect of creating an intimidating, hostile, or offensive work environment.

-Has the purpose or effect of unreasonably interfering with an individual’s work performance.

-Otherwise adversely affects an individual’s employment opportunities.

Harassing conduct includes but is not limited to the following:

-Epithets, slurs, negative stereotype, or threatening, intimidating, or hostile acts that relate to race, color, religion, gender, national origin, age, or disability; or

-Written or graphic material that demonstrates hostility or aversion toward an individual or group because of race, color, religion, gender, national origin, age or disability and that is placed on walls, bulletin boards, or elsewhere on the employer’s premises, or circulated in the workplace.

Harassment Complaint Procedure:

Employees encountering harassment should immediately tell the offending person that their actions are inappropriate and offensive. The employee shall document all incidents of harassment in order to provide the fullest basis for investigation. In addition, the employee shall notify their supervisor of the harassment and appropriate investigative and/or disciplinary measures may be initiated.

Sexual Harassment defined:

Sexual harassment is defined by the Equal Employment Opportunity Commission as “unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature” when:

-Submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment; or

-Submission to or rejection of such conduct by an individual is used as a basis for employment decisions affecting that person; or

-Such conduct has the purpose of effect of unreasonable interfering with a person’s work performance; or

-Such conduct creates an intimidating, hostile or offensive work environment.

Sexual Harassment may include but is not limited to the following:

-Explicit sexual propositions, sexual innuendo, suggestive comments, sexual oriented kidding” or “testing”, “practical jokes”, jokes about gender specific traits

-Foul or obscene language or gestures, displays or foul of foul or obscene printed or visual material

-Foul or obscene physical contact, such as patting, pinching, or brushing against another’s body

Sexual Harassment Complaint Procedure:

Any employee who believes that another employee is engaging in sexual harassment may file a complaint as soon as possible and will file within a reasonable period of time after the event (not more than 180 days).

No person filing a complaint under this policy or who legitimately assists another in the prosecution of any such complaint shall be subjected to retribution or retaliation of any kind of doing do.

Complaints filed under this policy shall be immediately investigated by the Human Resource Director or by an individual designated by the County Manager, in the event the Human Resource Director is unable to perform this function due to circumstances surrounding the complaint. The County Manager will be notified after if the Human Resource Director is unable to investigate the complaint. To the fullest extent practicable, the investigation will be kept confidential. A report of findings will be presented to the County Manger with in fifteen (15) days of the complaint and the employee shall be advised of the findings.

Adjudication:

If the findings indicate a possibility of sexual harassment a hearing will be set to further investigate the claim. The County Manager and the Personnel Officer shall designate a time for a hearing and notify the accused employee in writing at least ten (10) calendar days before the hearing and of the complaint and underling allegations. The accused employee may request one (1) postponement of no longer than (10) working days of the hearing upon receipt of the notice.

The accused employee shall be entitled to attend the investigation process and testify on their own behalf, and shall be entitled to confront and cross-examine the employee who filed the complaint. In the event that the complainant chooses not to attend the hearing and upon objection from the accused to the complainant’s absence, the complaint shall be dismissed and the accused deemed innocent of the allegations.

The accused employee shall be entitled to call witnesses on their behalf and to introduce evidence which pertains to the issues presented by the complaint and investigative report.

At the conclusion of the hearing, or within five (5) working days of the hearing, the County Manager shall inform the employee in writing the findings and results of the hearing concerning the innocence or guilt of the offense.

The findings of guilt must be supported by substantial, credible evidence that:

-the facts alleged by the complainant occurred, are true: and

-those facts constitute sexual harassment within the definitions of this policy; and

-the accused is the person who committed the acts amounting to sexual harassment.

If an investigation confirms that harassment has occurred, corrective action will be taken in accordance with the nature and extent of the offense. The County absolutely prohibits retaliation against any employee bringing a claim of sexual harassment.

Harassment and Sexual Harassment-False Accusations Procedure:

The County recognizes that false accusations of harassment and sexual harassment can have a serious effect on an innocent individual. Falsely accusing another of harassment or sexual harassment shall be disciplined in accordance with the nature and extent of the accuser’s claim.

McDowell County encourages employees to raise questions regarding the harassment policy with their immediate supervisor, their department head, the Human Resource Director or the County Manager.
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Date*

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Date
Article V. Drug and Alcohol Policy

Section 1. Purpose

The purpose of this Policy is to maintain a drug---free and alcohol---free workplace and to provide procedures for testing job applicants and employees for the use of illegal drugs, the improper use of prescription medications, and the misuse of alcohol.

Section 2. General Policy on Driving or Working under the Influence

Persons employed by the County shall not, under any circumstances report to work, work or operate County owned, leased, or rented vehicles, or personal vehicles while on County business, while under the influence of drugs, including prescription drugs, if it is the opinion of a competent medical authority that driving ability is impaired by such substances.

County employees shall not report to work, work or operate County owned vehicles while under the influence of or with the smell of beer or other intoxicating beverages on their breath.

Employees suspected to be in violation of this Section shall be immediately reported to the County Manager who may suspend the suspected violator without pay, allowances or benefits until an investigation is conducted. If it is determined that the employee is not in violation of this Section, the employee shall be returned to duty with no loss of remuneration or benefits. If the employee is found to be in violation of this Section, he/she shall be discharged for unacceptable personal conduct according to the procedures outlined in herein.

Section 3. Drug and Alcohol Testing

Purpose: The purpose of this Policy is to maintain a drug-free and alcohol-free workplace and to provide procedures for conducting screenings of job applicants and employees for the use of illegal drugs.

Definitions:

ACCIDENT– An occurrence involving any County employee while on-duty with a County-owned or personally-owned motor vehicle operating on a public road that results in a fatality; bodily injury to a person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident; or one or more motor vehicles incurring disabling damage as a result of the accident, requiring the vehicle(s) to be towed away from the scene. An accident is also an occurrence involving any County employee while on-duty operating heavy equipment and/or machinery that results in a fatality; bodily injury to a person who, as a result of the injury, immediately receives medical treatment away from the scene of the accident.

ALCOHOL ABUSE– Improper uses or use to excess of alcoholic beverages

ALCOHOL TEST– A test for the presence of alcohol in the body as determined through the use of a breath alcohol test, evidential breathalyzer test, or blood screening.

ALCOHOL DEPENDENCY REHABILITATION PROGRAM – A program designed to assist participants in controlling a dependency to alcohol, with the program being one that is commonly accepted by the medical community.

EMPLOYEE – Any Full Time, Part Time, temporary, reserve officer and/or contract employee with the County.

ILLEGAL DRUGS – Any controlled substance, or narcotic, as listed in Schedules I through VI of Section 202 of the Controlled Substances Act (21 USC 812) or Chapter 90, Sections 87- 94 of the North Carolina General Statutes, or a metabolite thereof.

ILLEGAL DRUG USE – The physical consumption of any amount of controlled substance as defined in ILLEGAL DRUGS, or a metabolite thereof.

POSITIVE SAMPLE – With the respect to the results of a test for illegal drugs, means a laboratory finding of the presence of an ILLEGAL DRUG(S) or a drug metabolite in the urine, hair or blood of an employee being tested; all positive tests will be confirmed using a different technology than was used for the first test. The second test does not include the test authorized for the employment finalist or current employee, under North Carolina General Statute 95-232 (f) and 13 North Carolina Administrative Code 20.0400.

REASONABLE DETERMINATION – Whereby the County Manager considers any personal observations and the written observations of the Department Head and concludes from such observations that an employee in question may have consumed an illegal drug(s) and/or may have consumed alcohol immediately before or during the work period.

REASONABLE SUSPICION – Whereby a Department Head and/or the County Manager have reasonably held, objective evidence that an employee in question may have consumed an illegal drug(s) and/or may have consumed alcohol immediately before or during the work period or is otherwise impaired.

SAMPLE FOR ILLEGAL DRUGS – The providing of urine, hair or blood used in testing to determine the presence of illegal drugs.

SUBSTANCE ABUSE REHABILITATION PROGRAM – A program designed to assist participants in controlling a dependency to any ILLEGAL DRUG(S), with the program being one that is commonly accepted by the medical community.

TEST FOR ILLEGAL DRUGS – A test, including providing the necessary sample of urine, hair or blood by the employee being tested, for the presence of any of the controlled substance, as defined in ILLEGAL DRUGS.

TERMINATED – Whereby the County Manager ends an employee’s work with the County either by immediate dismissal or by accepting his or her letter of resignation.

Section 4. Pre- Employment Screening

As a post-offer, pre-employment condition of employment, all finalists for any employment position with the County shall take a test for illegal drugs within eight (8) hours of being directed to do so. Any finalist who delays or refuses to provide a sample for illegal drugs shall not be further considered for employment. The results of the test for illegal drugs shall be provided to the County before any position may be offered. A position shall not be offered to any finalist who provides a positive illegal drug sample. A finalist who provides a positive illegal drug sample shall be notified of his/her rights to retest the sample, pursuant to North Carolina General Statute 95-232 (f) and 13 North Carolina Administrative Code 20.0400.

Furthermore, any post-offer, pre-employment finalist who provides a positive illegal drug sample shall not be considered for any employment with the County for a period of one (1) year from the date of the positive illegal drug sample. Moreover, any finalist who provides a positive illegal drug sample shall not be considered for employment until the applicant completes a substance abuse rehabilitation program, to be completed following the positive illegal drug sample.

Section 5. Reasonable Suspicion Testing

The County Manager shall direct a test for illegal drugs and/or alcohol test to be taken by an employee in question immediately, not to exceed four (4) hours, of making the reasonable determination that the employee has used an illegal drug(s) and/or consumed alcohol immediately before or during work period. The employee in question shall be transported, by the County, to the testing location. The reasonable determination shall be based, in part, on the written observations of the Department Head and /or the County Manager of the employee in question’s behavior leading to the reasonable suspicion of illegal drug use and/or alcohol use. Credible reports of impairment or intoxication from reliable third-party sources may also be considered, subject to corroboration. Written observations shall be signed and completed within two (2) hours of the actual observation. Under this section, any employee in question who delays or refuses to provide either sample shall be immediately suspended without pay for a period not to exceed seven (7) days from the date of delay or refusal. During the suspension, the County Manager shall make the determination whether the delay or refusal warrants additional disciplinary action up to termination. The employee in question shall provide a written and signed statement explaining his or her actions for delaying or refusing to provide either sample.

If an employee in question provides a positive alcohol sample under this section, the employee shall be immediately transported, by the County, to his or her primary residence and shall be suspended without pay for a period not to exceed seven (7) days from the date of the positive sample. During the suspension the County Manager shall make the determination whether the positive alcohol sample warrants disciplinary action up to termination. The County Manager shall take into account that individuals recovering from addictions may qualify for protection and accommodation under federal and state disability laws.

An employee in question who provides a positive drug sample shall be notified of his/her rights to retest the sample, pursuant to North Carolina General Statute 95-232 (f) and 13 North Carolina Administrative Code 20.0400. If an employee in question provides a positive illegal drug sample under this section, the employee in question shall be terminated.

Section 6. Post-Accident Testing

Any employee involved in any accident and deemed responsible by the police report shall be required to take a test for illegal drugs and/ or alcohol test, immediately following the accident, not to exceed four (4) hours. The employee shall be transported to the testing location by the County.

Under this section, any employee who delays or refuses to provide either sample shall be immediately suspended without pay for a period not to exceed seven (7) days from the date of the delay or refusal. During the suspension, the County Manager shall make the determination whether the delay or refusal warrants additional disciplinary action up to termination. The employee shall provide a written and signed statement explaining his or her actions for delaying or refusing to provide either sample.

If the employee provides a positive alcohol or drug sample under this section, the employee shall be transported, by the County, to his or her primary residence and shall be suspended without pay for a period not to exceed seven (7) days from the date of the positive sample. During the suspension, the County Manager shall make the determination whether the positive alcohol or drugs sample warrants disciplinary action up to termination. The County Manager shall take into account that alcohol abuse is considered to be a disability.

An employee who provides a positive illegal drug sample shall be notified of his/her rights to retest the sample, pursuant to North Carolina General Statute 95-232 (f) and 13 North Carolina Administrative Code 20.0400. If an employee provides a positive illegal drug sample under this section, the employee shall be terminated.

Section 7. Re-Employment of a Terminated Employee

Any employee terminated under the terms of this Policy shall not be considered for reemployment with the County for a period of one (1) year from the date of termination.

Furthermore, the former employee shall not be considered for re-employment until the former employee completes a substance abuse rehabilitation program and/or alcohol dependency rehabilitation program, to be completed following the positive illegal drug sample and/or positive alcohol test.

Section 8. Confidentiality

Records concerning any employee’s involvement with this Policy shall be confidential and only released in conformance with North Carolina General Statutes 160A-168 and 13 North Carolina Administrative Code 20.0500.

Section 9. Enforcement

The County Manager shall be responsible for the enforcement of this Policy.

Section 10. Severability

Any section of this Policy determined to be inconsistent with Federal, State and/or common law shall not be enforced and shall not interfere with the enforcement of the remaining sections of the Policy.
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Date*

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Life Insurance Beneficiary
Employee Legal Name (First, M.I., Last)*
Address*

Home Address

Street Address Line 2

CityState

Zip
Telephone Number*
Social Security #*
Date of Birth*

MonthDayYear
Date
Marital Status*
Gender*

FemaleMale
Primary Beneficiary Designation
Beneficiary Name (Last, First, MI)*
Beneficiary Address*
Beneficiary Social Security Number*
Beneficiary Birthdate*
Beneficiary Relationship to You*
Percentage of Benefits that goes to this Beneficiary (enter 100% if this is the only primary beneficiary that you are naming. If you name another below, enter a different amount. The two percentages must equal 100%) *
Primary Beneficiary Designation #2 (optional)
Beneficiary Name (Last, First, MI)
Beneficiary Address
Beneficiary Social Security Number
Beneficiary Birthdate
Beneficiary Relationship to You
Percentage of Benefits that goes to this Beneficiary (The two percentages must equal 100%)
Contingent Beneficiary Designation (optional) (Will receive proceeds if Primary beneficiaries are not living)
Beneficiary Name (Last, First, MI)
Beneficiary Address
Beneficiary Social Security Number
Beneficiary Birthdate
Beneficiary Relationship to You
Percentage of Benefits that goes to this Beneficiary
I represent that the information provided above is true and correct. I understand that if I am not actively at work on the effective date of my coverage, my insurance will not begin until the day I return to work. For those coverages I have declined, I understand that if I choose to enroll at a later date, Evidence of Insurability may be required. If the Plan provides that any contributions be made by me, I authorize my employer to deduct them from my pay.

Warning - It is or may be a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purposes of defrauding the company or other person. Penalties may include imprisonment, fines, and a denial of insurance benefits in accordance with applicable state law.
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401K/457 Elections

Planning for your Retirement!
If you hope to enjoy a more financially secure retirement tomorrow, it makes sense to start planning for it today. A great way is by contributing to the NC 401(k) and the NC 457 Plans, because you'U enjoy:

It's your choice. Contributions are payroll deducted as traditional pre-tax, Roth (after-tax), or both-and you are atways 100 percent vested. Contribution rates may be changed at any time.

Loans and hardship withdrawals are available white you're still working, restrictions may apply.

Rollovers. Rollovers are accepted from previous employers' retirement plans and many IRAs. Pre-approval from Prudential is required.

One-on-one support. Your Retirement Education Counselor is Deborah Rapetski. Deborah is a local, salaried retirement educator who is available to help you by phone, email or in person.
Have a former employer's retirement plan balance?

I am interested in rolling over my outside retirement plan(s).
Choosing a Retirement Plan
Please choose a retirement plan. McDowell County will contribute a percentage to the plan of your choice. For more information about the differences between the two plans, please refer to the orientation materials provided by Human Resources.*

401K457
OPTIONAL: If you chose the 401K plan and would like to contribute an additional amount toward your retirement, please enter the amount or percentage you would like to contribute. (Remember, the amount or percentage is taken from your check each pay period. An additional contribution is optional and can be changed at any time.)
Enter a percentage or dollar amount and whether you would like it to be pre-taxed or post-tax.
OPTIONAL: If you chose the 457 plan and would like to contribute an additional amount toward your retirement, please enter the amount or percentage you would like to contribute. (Remember, the amount or percentage is taken from your check each pay period. An additional contribution is optional and can be changed at any time.)
Enter a percentage or dollar amount and whether you would like it to be pre-taxed or post-tax.
Print Name*
Email Address*
example@example.com
Social Security Number*
Date of Birth*

MonthDayYear
Date
Date of Hire

MonthDayYear
Date
Phone*
Address*
City, State, Zip*
Check this box ONLY if you are a sworn Law Enforcement Officer (LEO)

Yes, I am a sworn LEO
Primary Beneficiary Designation

(If you would like to select more than one primary beneficiary, please contact Human Resources for an additional page)
Name*
Social Security Number*
Beneficiary's Relationship to You*
Your Signature*

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Date*

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Acknowledgement Form
I acknowledge and confirm that I have completed the McDowell County Orientation. I understand that I have access to the updated personnel manual and the standard operating procedures which are on the Human Resources Portal; I also may request these from Human Resources at any time. Furthermore, I understand that I am governed by the contents of both the personnel manual and the standard operating procedures and it is my responsibility to familiarize myself with them.
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Date*

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Form 2C Designating Beneficiary(ies)
Employee Information
First Name*
M.I.
Last Name*
Suffix
SSN (Last 4 digits)*
Mailing Address*
City*
State*
Zip Code*
Telephone*
Date of Birth*

MonthDayYear
Date
Beneficiary(ies) Information
First Name*
M.I.
Last Name*
Date of Birth*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

ZIP
Relationship*
Social Security Number*
E Mail Address
example@example.com
Telephone Number
OPTIONAL: If you would like to add a Contingent beneficiary, do so here.
First Name
M.I.
Last Name
Date of Birth

MonthDayYear
Date
Address

Address

Street Address Line 2

CityState

ZIP
Relationship
Social Security Number
E Mail Address
example@example.com
Telephone Number.
If you would like to add more than one Primary or Contingent Beneficiaries, please contact Human Resources for additional paperwork.

Years of Service in LGERS

(Local Government Employees Retirement System)
If you were a participating member of the Local Governmental Employees' Retirement System (LGERS) via a prior job with a county entity, please list the dates and locations.
County(ies)
Dates
If you have withdrawn/closed funds from previous LGERS systems, those cannot be accounted for in determining vacation accrual rates with McDowell County.
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Decline Medical Coverage Form

Only complete this step if you chose to decline medical coverage. If you did not decline, move on to the next page.
I received and read a copy of the "Notice of HIPAA Special Enrollment Rights" (the Notice) at or before the time I was initially offered enrollment in McDowell County Group Health Plan (the Plan I am aware of the warning in the Notice that I will lose some special enrollment rights for myself and my dependents if I decline coverage because I or my dependents have other coverage, unless I give the Plan this written statement with the reason I am declining coverage. Furthermore, the Group Health Plan will retain this Form for purposes of the Patient Protection and Affordable Care Act's Employer Shared Responsibility provision.
Please check the reason for your decline coverage (i.e., the source of other coverage):

Spouse's employer-sponsored group health planDependent's employer-sponsored group health planIndividual PolicyMedicaid or CHIPMedicareTricareCOBRA from a previous employer
If none of the above, please explain:
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Thank you for completing your New Hire Paperwork!
- Please make sure that Human Resources has a voided check or a direct deposit form from your bank. This needs to be submitted in-person at 25 West Fort Street, Marion (back and bottom of the building) NOTE: If you are going from Part-Time to Full-Time, you do not need to submit banking information.
- All Full-Time employees: Please call Human Resources and schedule a time to come in and sign your FORM 2C in person. At this time, you can bring your banking information.
Should be Empty:

Employee Emergency Contact Form

Optional (the following information is optional and will not be used in a discriminatory manner)

Emergency Contact Information

W-4: Employee's Withholding Certificate

Claim Dependent and Other Credits

Additional Information:

NC-4: Employee's Withholding Allowance Certificate

Direct Deposit Authorization

McDowell County Policies

Life Insurance Beneficiary

401K/457 Elections

Acknowledgement Form

Form 2C Designating Beneficiary(ies)

Years of Service in LGERS

Medical/Dental/Vision Coverage

Decline Medical Coverage Form