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Department of Administrative Services


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Acknowledgment of Driver License Requirement
Administrative Rule Waiver Request
Affidavit as to Forged Endorsement
Affidavit of Common Law Marriage
AFSCME Third Bumping Option
Agreement for Recouping Education Payments 552-0707
AO Safety Glasses Form
Appeal Board Administrative Form
Authorized Signature Form


Background Check Policy Template
Bargaining Exemption Questionnaire
Building Access Identification Cards


Calculate Market Value Differential
Calculating Mortgage Interest Differential
Calculation of AFSCME Seniority
Calculation of Income Tax Assistance Payment
Calculation of UE/IUP Seniority - Science Unit
Calculation of UE/IUP Seniority - Social Services Unit
Capitol Complex Events Form
Certificate of Creditable Coverage - Health
Certificate Program Enrollment Forms
Certification of Full-Time Student Status
Certified Public Manager (CPM) Application
CFN 552 Refund Form
CFN 552 State Share Transfer
CFN 552 TRA Form
CFN 552 Transfer Between Carriers Form
Classification Selective Changes
Coaching Questionnaire — PDF (Performance & Development Solutions)
Coaching Questionnaire — Word (Performance & Development Solutions)
COBRA Notification/Election form
Commercial Driver License Supplement Application
Common Law Marriage, Affidavit of
Confidential Personal Data Form
Confined Space Entry Permit (Permit Required)
Confined Space Pre-Entry Checklist (Non-Permit Spaces)
Correction Document Expenditure - Excel Version
Correction Document Expenditure - Word Version
Correction Document Revenue - Word Version
Correction Document Revenue - Excel Version
CR Cash Receipt Treasurer's Document

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Delta Dental Insurance Application
Dig Application
Direct Pay Continuation Form
Donated Leave Application
Donated Leave Application for Family Members
Domestic Partner Affidavit
Domestic Partner Termination
Donated Leave Contributions
Donated Leave Contributions for Family Members
Donated Leave Request
Donated Leave Request for Family Members
Donated Leave Tracking
Donated Leave Tracking for Family Members
Double Spouse Credit Toward Family Dental and Health Insurance
Duplicate W2 Request Form
Duplicate Warrant Affidavit


Education Payments: Agreement for Recouping Education Payments 552-0707
Educational Directory order form
Educational Leave Assistance
EFT Authorization State of Iowa Vendor Use Only (Not for Employee Payroll Use)
Emergency Procurement Justification Form
Employee Separation
Employee Request for Emergency Evacuation Assistance
Evacuation Assistance form, Employee Request for
Exit Information Questionnaire Part 1
Exit Information Questionnaire Part 2


First Report of Injury or Illness
FMLA Application & Intent to Return to Work
FMLA - Cert. of Health Care Provider for Employee's Serious Health Condition
FMLA - Cert. of Health Care Provider for Family Member's Serious Health Condition
FMLA - Cert. of Qualifying Exigency for Military Family Leave
FMLA - Cert. for Serious Injury/Illness of Covered Service Member for Military Family Leave
FMLA - Certification for Serious Injury or Illness of a Veteran for Military Caregiver Leave
FMLA - Designation Notice
FMLA - Leave Retention
FMLA - Notice of Eligibility and Right & Responsibilities
FMLA - Return to Work Certification

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GAX for Interfaces-Excel Version
GAX for Interfaces-Word Version
GAX with Accounting Lines - Word Version
GAX With Accounting Lines - Excel Version
GAXN-Excel Version
GAXN-Word Version
GAXR-Excel Version
GAXR-Word Version


Health Insurance Application: Regular Health Plans (except Blue Advantage)
Health Insurance Application: Blue Advantage
Health Insurance Application: Alliance Select (SPOC-covered employees only)
Health Insurance Opt-Out
Healthy Opportunities Participation Election
Hiring Justification
Hot Work Permit


IET Internal Exchange Transfer-Excel Version
IET Internal Exchange Transfer-Word Version
IET for PROD Interfaces - Word Document
IET for PROD Interfaces - Excel Document
IETN-Excel Version
IETN-Word Version
IETR-Excel Version
IETR-Word Version
Intern Development Program form
Intern Hire Data
Internship Completion Data
Internship Development Program Application
Inventory Worksheet
Involuntary Loss of Coverage Statement
IRS Tests for Preparing Relocation Expense Claims
IT Procurement Request Form

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Job Evaluation Questionnaire
JV General Journal Voucher-Excel Version
JV General Journal Voucher-Word Version
JV1 Correcting Journal Voucher-Excel Version
JV1 Correcting Journal Voucher-Word Version
JV1N-Excel Version
JV1N-Word Version
JV1R-Excel Version
JV1R-Word Version



Lease Agreement, State of Iowa
Life Insurance -- Claim Form
Life Insurance -- Claim Form Instructions
Life Insurance -- Notice of Continuation of Coverage
Life Insurance - Personal Health Application
Life Insurance -- Waiver of Life Insurance Form

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MD Cover Sheet
MD-Excel Version
MD-Word Version
Merit Exempt Questionnaire
Motor Vehicle Law Conviction Notice
Mover Planner Worksheet
Moving Company Bid


Non-contract Grievance form


Office Space Allocation Form
Online Learning Registration Form
Outplacement/Recall Enrollment Form

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P17 Electronic Work Comp
Parking Decal Application
Pay Grade Study Questionnaire
PDS Course Registration Form
Performance Plan and Evaluation form
Permit-Required Confined Space Entry Permit
Personnel Mobility Assignment Agreement
Personnel Services Pre-Contract Questionnaire
Position Description Questionnaire
Pre-Auditor's Authorized Signature Form
Pre-Entry Checklist for Non-Permit Confined Spaces



Reasonable Accommodation Request
Relocation: Agreement for Recouping Relocation Payments 552-0751
Relocation Expense Recap (sample)
Relocation TP & JV1 Cover Sheet
Request for Exception to Statewide Policies
Request for Flat WH Rates
Request for Intern List
Request for Outstanding Warrant Action
Request to Decrease Supplemental Life Insurance
Request to Establish New Fund
Requisition for Goods & Services Form
Retention Point Calculation Worksheet
RIC Account Form
RIC Beneficiary Form (fill-in)
RIC Beneficiary Form (printable)
RIC Distribution Form
RIC Rollover Form
RIC Unforeseeable Emergency Form

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Separation Checklist
Short Form SS-8
Signature Authorization form
SLIP - Application for the Retired/Disabled State Group Health or Dental Insurance
SLIP - Enrollment Form
SLIP - Calculation Worksheet
SLIP - Enrollment Checklist for HRA/PA
SLIP - Executive Branch Non Contract SLIP Retiree Wellness Participation
SLIP - Retiree Rehire Authorization
Sole Source Purchase Form
Space Allocation Form
Special Pay/Appointment Request
Specials Cover Sheet
SPOC Vacation to Sick Leave Conversion
State of Iowa Employment Application
Statement of Ownership of Principle Residence
Substitute W-9 Vendor
Summary of Internal Policies for Claims Crossing FY
Supervisory Analysis Questionnaire
Supplemental Life Insurance Application Form
Supplemental life Insurance, Request to Decrease


TA (PERM)-Excel Version
TA (PERM)-Word Version
TA (TEMP) with Accounting Lines -- Excel Version
TA (TEMP) with Accounting Lines -- Word Version
TAPE Cover Sheet
TE-Excel Version
TE-Word Version
Temporary Staffing Services Vendor Request
TP (Travel Payment) with Accounting Lines -- Excel Version
TP (Travel Payment) with Accounting Lines -- Word Version
TPN-Excel Version
TPN-Word Version
TPO-Excel Version
TPO-Word Version
TP-RELO EXP-Travel Payment for Relocation Expense
TP-RELO-SUB-Travel Payment for Relocation Subsistence
TPR-Excel Version
TPR-Word Version



Vehicle Accident Report Form
Vendor Complaint Form
Vendor Conversion Form
Veterans: Participation Request Form: Non-Competitive Hiring Program for Disabled Veterans
Veterans: Time Tracking Form: Work Experience/Training Program for Disabled Veterans


Waiver of Administrative Rule Request
Waiver of Life Insurance Form
Wallace Auditorium Reservation Form
Workers' Comp Benefit Election Form
Workers' Comp Status Report
Workers' Comp Travel Reimbursement Request
Workers' Comp Wage Statement
Workplace Violence Report




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Updated 2015/01/15