STATE OF FLORIDA AGENCY BENEFICIARY PAYROLL CERTIFICATION AND WORKSHEET

AGENCY PAYROLL CERTIFICATION

Pursuant to requirement by law, I respectfully requisition salary payments for the accounts as indicated below for the persons employed by this agency or division of State government. You are hereby authorized
to prepare warrants to all persons in this agency or division in the amount shown in the system or on attached documents. I certify, any changes have been submitted in compliance with all provisions of the
Legislative Appropriations Act and all other statutes governing salaries; all persons for whom salary warrants are requisitioned are bona fide employees of this agency or division and have earned the amount
requisitioned and certified by performing duties as required by their authorized position as recorded in our approved budget.

PAYMENT TYPE FLAIR ACCOUNT CODE FLAIR ORG CODE INTRADEPARTMENT #:

REGULAR SALARY/WAGES
OPS SALARY/WAGES
ALL LEAVE TYPES
OVERTIME
ON-CALL FEES
TOLL ALLOWANCE
UNIFORM ALLOWANCE
CJIP
OTHER

I further certify that loyalty oaths and requests for miscellaneous deductions are on file in this office. All necessary documents, as indicated below, have been forwarded to our office before the scheduled deadline
as set by the Payroll Processing Schedule.

DATE: Prepared by: Telephone Number: OLO:

DATE: AUTHORIZED BY: TELEPHONE NUMBER:

**NOTE: THE AUTHORIZED SIGNER OF THIS DOCUMENT MUST HAVE AN AUTHORIZED SIGNATURE FORM ON FILE WITH THE BUREAU OF STATE PAYROLLS.
BENEFICIARY PAYMENT REQUIRED DOCUMENTATION
BENEFICIARY DOCUMENTATION REQUIRED FROM THE AGENCY DECEASED EMPLOYEES DATES OF SERVICE:
Beneficiary Affidavit(s) Form (DFS-A3-1912): Death Certificate: Begin Service Date:
IRS Form W-9 Taxpayer ID# Certification: Letter of Administration if Applicable: End Service Date:

DECEASED EMPLOYEE INFORMATION

PLEASE PROVIDE ALL REQUESTED INFORMATION IN THIS SECTION BIWEEKLY AND/OR MONTHLY RATE OF PAY REGULAR AND/OR OPS SALARY/WAGE PAY PERIOD BEGIN AND END DATES
SSN#: PAY CYCLE Biweekly Period Rate of Pay: CS/SES/SMS BEGIN: END:
LAST NAME: CLASS CODE: Biweekly Hourly Rate of Pay: OPS-BIWEEKLY BEGIN: END:
FIRST NAME: PAY PLAN: OPS Hourly Rate of Pay:
MI: APT CD: Monthly Period Rate of Pay: CS/SES/SMS BEGIN: END:
DECEASED DATE OF DEATH: 12/30/99 RET CD: Monthly Hourly Rate of Pay: OPS-MONTHLY BEGIN: END:

BENEFICIARY REGULAR SALARY/WAGE PAYOUT INFORMATION

BIWEEKLY SALARY/WAGES BIWEEKLY ROP CONTRACT HRS HRS HRS PAID GROSS TROP HOURLY RATE OF PAY CALCULATION WITH/WITHOUT CJIP
9170 - Regular Salary/Wages $0.00 80 0.0 $0.00 1 PAYROLL TYPE BIWEEKLY MONTHLY CJIP HOURLY CALCULATION
9171 - OPS Salary/Wages $0.00 0.0 $0.00 2 PERIOD RATE
MONTHLY SALARY/WAGES MONTHLY ROP CONTRACT HRS HRS HRS PAID GROSS TROP PLUS PAY ADDITIVE 0.00
9170 - Regular Salary/Wages $0.00 0.0 $0.00 1 TOTAL GROSS $0.00 $0.00 *NOTE: Hourly Rate of Pay
9170 - Regular Salary/Wages 0.0 $0.00 1 HOURLY ROP $0.00 $0.00 May Vary by a Penny in
9171 - OPS Salary/Wages $0.00 80 0.0 $0.00 2 ROP WITH CJIP $0.00 $0.00 People First.

DFS-A3-2123 Page 1
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 STATE OF FLORIDA AGENCY BENEFICIARY PAYROLL CERTIFICATION AND WORKSHEET
TOTAL GROSS $0.00

BENEFICIARY LEAVE PAYOUT INFORMATION

LEAVE TYPE HOURLY ROP HRS HRS PAID GROSS TROP FINAL WARRANT INFORMATION
9108 - Annual Leave $0.00 0.0 $0.00 2 Warrant Issued Before/After Date of Death
9123 - Sick Leave @ 1/4 $0.00 0.0 $0.00 7 Warrant Cancelled by the Agency
9111 - Special Comp Leave $0.00 0.0 $0.00 2
9121 - Other Special Comp Leave $0.00 0.0 $0.00 2
TOTAL GROSS $0.00
SICK LEAVE CERTIFICATION: I hereby certify that the above information is correct and the named employee has not forfeited the right to this sick leave payment for any reason under Subsection 110.122(5), F.S.

BENEFICIARY OVERTIME PAYOUT INFORMATION

LEAVE TYPE HOURLY ROP HRS HRS PAID GROSS TROP

9124 - Overtime/Straight Time: $0.00 0.0 $0.00 3
9124 - Overtime/1 1/2 Times: $0.00 0.0 $0.00 4
9124 - OPS OT/Straight Time: $0.00 0.0 $0.00 3
9124 - OPS OT/1 1/2 Times: $0.00 0.0 $0.00 4
TOTAL GROSS $0.00

BENEFICIARY ON-CALL FEES , TOLL ALLOWANCE, UNIFORM ALLOWANCE, AND MISCELLANEOUS DEDUCTION PAYOUT INFORMATION

PAYMENT TYPE BEGIN RATE TROP PAY AMOUNT MISCELLANEOUS DEDUCTIONS AMOUNT BENEFICIARIES
9117 - On-Call Fees 1 $0.00 0042 - Medical Reimbursement
PAYMENT TYPE BEGIN RATE TROP PAY AMOUNT NOTE: DOCUMENTATION REQUIRED
9163 - Toll Allowance (TA) 1 $0.00 MISCELLANEOUS DEDUCTIONS AMOUNT
PAYMENT TYPE BEGIN RATE TROP PAY AMOUNT 0200 - Salary Refund
9106 - Uniform Allowance (UA) 1 $0.00
PAYMENT TYPE BEGIN RATE TROP PAY AMOUNT MISCELLANEOUS DEDUCTIONS AMOUNT
OTHER: 1 $0.00
TOTAL GROSS $0.00

BENEFICIARY CJIP PAYOUT INFORMATION

LEAVE TYPE CJIP PAY AMOUNT PAY MONTH DAYS IN MONTH DAILY ROP DAYS WORKED GROSS TROP
9172 - CJIP $0.00 $0.00 1
9172 - CJIP $0.00 $0.00 1 TOTAL GROSS $0.00

BUREAU OF STATE PAYROLLS USE ONLY

Date BENE PACKET Received:

PROCESSED BY: DATE: Date BENE OD Processed:

APPROVED BY: DATE:

DFS-A3-2123 Page 2
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 STATE OF FLORIDA AGENCY BENEFICIARY PAYROLL CERTIFICATION AND WORKSHEET

t. You are hereby authorized

ith all provisions of the
have earned the amount

efore the scheduled deadline

OLLS.

EES DATES OF SERVICE:

PERIOD BEGIN AND END DATES

ION WITH/WITHOUT CJIP

CJIP HOURLY CALCULATION

0.00
*NOTE: Hourly Rate of Pay
May Vary by a Penny in
People First.

DFS-A3-2123 Page 3
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 STATE OF FLORIDA AGENCY BENEFICIARY PAYROLL CERTIFICATION AND WORKSHEET

NT INFORMATION
ed Before/After Date of Death
ancelled by the Agency

5), F.S.

T INFORMATION

BENEFICIARIES
Wife
Husband
Child
# of Children
Mother
Father
Legal Rep.

ACKET Received:

OD Processed:

DFS-A3-2123 Page 4
Rev. 01/03/2017
 STATE OF FLORIDA
AGENCY BENEFICIARY PAYROLL CERTIFICATION
AND BENEFICIARY WORKSHEET

OVERVIEW:

This form was designed to be completed on-line and emailed to the Bureau of State Payrolls
(BOSP) as a password protected document. A signed copy is not required but this form must be
emailed to the BOSP by the agency representative that authorized the payment. The agency
representative is required to have a current Authorized Signature Form (DFS-A3-1930) on file with
the BOSP. If the BOSP does not have an Authorized Signature form on file the agency
representative will be notified to submit one. Agencies will continue to submit the Beneficiary
Affidavit (DFS-A3-1912) along with the IRS Form W-9 Taxpayer ID# Certification, Death
Certificate and Letter of Administration (if applicable). Copies of the Death Certificate must be
legible and the BOSP needs the original signed Beneficiary Affidavit(s) (DFS-A3-1912). When
an agency is notified that an employee is deceased the BOSP should be contacted immediately. The
agency is not required to have a completed Beneficiary Packet at the time that the BOSP is notified.

To easily maneuver through the worksheet use the Tab Keys or the Arrow Keys. The Tab and
Arrow Keys will take you only to the cells in the worksheet that the agency can populate. All other
cells are locked and cannot be altered in anyway. This is a password protected document and all
agencies should use the password that has been designated by the BOSP for the submission of
information that is of a confidential nature.

Cells that contain blue or red font are cells that will populate or calculate automatically. Some
blank cells contain dropdown boxes while others may not. A cell containing a dropdown box will
show a down arrow on the side of the cell when the cell is clicked on. Click on the down arrow and
it will give a list of options. Select the proper option and click on it to populate that cell.

INSTRUCTIONS FOR COMPLETING THE FORM

AGENCY PAYROLL CERTIFICATION SECTION:

This section contains a list of payments that the deceased employee's beneficiary may be entitled to
receive: Regular Salary/Wages, OPS Salary/Wages, All Leave Types (i.e. Annual Leave, Sick
Leave, Special Compensation Leave, FLSA Special Compensation Leave), Overtime, On-Call
Fees, Criminal Justice Incentive Pay (CJIP), Toll Allowance, Uniform Allowance, and Other.
Locate the appropriate payment type and enter the FLAIR Account Code and the FLAIR Org Code.
The Intradepartment Number field is optional. When entering the FLAIR Account Code the first
11 digits of the account code will be placed into the first cell, the next 10 digits will be placed into
the second cell, and the last 8 digits into the third cell. There is no need to enter dashes. Dashes
will automatically populate when the numbers have been enter and the cursor has been moved to
the next cell.

Complete the Preparer and Authorizer Information.

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BENEFICIARY DOCUMENTATION REQUIRED FROM THE AGENCY SECTION: The
blank cells in this section have dropdown boxes containing Yes, No, or N/A.

The Deceased Employees Dates of Service: Enter the correct information into the blank cells. A
date format has been provided (mm/dd/yy). The End Service Date is the date that the employee
became deceased and will automatically populate the Deceased Date of Death cell and the Pay
Period End Date cell.

DECEASED EMPLOYEE INFORMATION SECTION: All information is required to be

completed in this section. The SSN# will automatically populate the dashes once the number has
been entered. Pay Cycle, Pay Plan, APT Code, and RET Code contain dropdown boxes. Click on
each dropdown box and select the correct information from the list under each dropdown box.
Most of the information can be found on the employee's Last Payment Detail Screen in FLAIR
PYRL.

For Beneficiary Payments that consist of only Regular Salary/Wages the Pay Cycle should be "1"
for Biweekly or "2" for Monthly. A Pay Cycle "3" for Biweekly or a Pay Cycle "4" for Monthly
should be used when Regular Salary/Wage Payments are submitted along with payments for other
types of leave.
Biweekly and/or Monthly Rate of Pay: This section is very important and must be completed
correctly using the correct Period Rate of Pay and Hourly Rate of Pay for the proper Payroll (i.e.
Biweekly or Monthly). The cells containing the Period Rate of Pay and Hourly Rate of Pay will
automatically populate other cells contained within the worksheet. If the employee is due OPS
Wages a cell has been provided for the deceased employee's Hourly Rate of Pay.

BENEFICIARY REGULAR SALARY/WAGE PAYOUT INFORMATION: Enter only the

HRS for Biweekly Regular Salary/Wages and OPS Regular Salary/Wages. The BIWEEKLY ROP,
HOURS PAID and GROSS will populate automatically. For Monthly Regular Salary/Wages enter
only the CONTRACT HRS and the HRS. The MONTHLY ROP, HRS PAID and the GROSS will
populate automatically. An extra line has been provided for Monthly Regular Salary/Wages to
accomodate Regulary Salary/Wages that may have been worked in a previous Month. In this extra
line the CONTRACT HRS and the HRS must be entered. The HRS PAID and the GROSS will
automatically populate. Enter only the HRS for Monthly OPS Regular Salary/Wages. The
MONTHLY ROP, HRS PAID and the GROSS will populate automatically.

NOTE: A deceased employee shall not be paid for work hours, leave, or holiday credits to
cover scheduled hours occurring after the date and time of death, as determined by the
death certificate. Agency questions should be directed to the BOSP.

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Hourly Rate of Pay Calculation With/Without CJIP: This section has been designed to assist
agencies in calculating the Total Gross and Hourly Rate of Pay when a deceased employee has a
pay additive. In this section CJIP can be calculated and will only be added to the Hourly Rate of
Pay. Biweekly and Monthly employees receive CJIP Pay Separate from Regular Salary/Wages.
Biweekly and Monthly Hourly Rate of Pay is used to calculate Leave Payouts. In this section the
only cells that require input are the Period Rate and/or Pay Additive as well as the blank cell
underneath CJIP Hourly Calculation. The blank cell contains a dropdown box listing the different
CJIP Pay Amounts. Click on the correct pay amount to populate that cell. If this section is used the
individual entering the information must enter the information into the Biweekly and/or Monthly
Rate of Pay Section of the worksheet under Deceased Employee Information.

BENEFICIARY LEAVE PAYOUT INFORMATION SECTION: Enter only the HRS. The
HOURLY RATE of PAY, HRS PAID and the GROSS will populate automatically. The Sick
Leave HRS entered should be the total number of hours that the deceased employee had remaining
as of his/her date of death. The HRS PAID field will show the hours to be paid divided by 1/4 or
1/8 and at the proper cap.

Reminder: A deceased employee’s entire Annual Leave balance is paid to a Beneficiary and Sick
Leave can only be paid to a deceased employee who has earned 120 retirement credits.

Annual Leave – Per 60L-34.0041 (6)(a) and (6)(b) F.A.C., “In case of death of an
employee, the 240-hour limit shall not apply and all unused annual leave at the time of
death shall be paid to the employee’s beneficiary, estate, or as provided by law. In case
of death of an employee, the 480-hour limit shall not apply and all unused annual leave at
the time of death shall be paid to the employee’s beneficiary, estate, or as provided by
law."

SICK LEAVE - Pursuant to 110.122, F.S., “The payments authorized by this section shall be
determined by using the rate of pay received by the employee at the time of retirement, termination,
or death, applied to the sick leave time for which the employee is qualified to receive terminal
"incentive" pay under the rules adopted by the department pursuant to the provisions of this section.
Rules and policies adopted pursuant to this section shall permit terminal pay for sick leave equal to
one-eighth of all unused sick leave credit accumulated prior to October 1, 1973, plus one-fourth of
all unused sick leave accumulated on or after October 1, 1973. However, terminal pay allowable
for unused sick leave accumulated on or after October 1, 1973, shall not exceed a maximum of 480
hours of actual payment. Employees shall be required to use all sick leave accumulated prior to
October 1, 1973, before using sick leave accumulated on or after October 1, 1973."

Special Compensatory Leave and FLSA Special Compensatory Leave: Special Comp Leave and
FLSA Special Comp Leave may be paid to the beneficiary only if doing so is consistent with your
agency’s policies and rules as well as any applicable collective bargaining provisions. It is the
agency’s responsibility to determine whether or not the employee was eligible to be paid for any
special compensatory leave hours.

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Final Warrant Information: Indicate if a warrant was issued before or after the date of death and if
the warrant was cancelled by the agency. Each blank cell has a dropdown box containing Yes, No
or N/A. Click on the Dropdown box and then click on the correct response.

NOTE: In the event that an employee's last pay warrant was not cancelled, a detailed explanation
must accompany this attachment via email explaining the reason why the employee’s final warrant
was not cancelled by the agency.

BENEFICIARY OVERTIME PAYOUT INFORMATION: Enter the number of hours in the

HRS section of the form. The HOURLY RATE of PAY, HRS PAID and the GROSS will
automatically populate once the HRS information has been entered. There are fields for Regular
Salary/Wage and OPS Wages for Overtime paid at Straight Time and Overtime paid at 1 1/2 times
the employee’s rate of pay.
BENEFICIARY ON-CALL FEES, TOLL ALLOWANCE, UNIFORM ALLOWANCE AND
MISCELLANEOUS DEDUCTION PAYOUT INFORMATION SECTION: On Call Fees,
Toll Allowance and Uniform Allowance Payments should be entered into the proper section of the
form. The Begin Rate should be the entire pay amount and will automatically populate the PAY
AMOUNT field of the form. If there should be a payment that is not included in this form use the
“OTHER” field and supply an earnings code in the blank cell beside “OTHER”.

Miscellaneous Deductions: Three fields have been provided for Miscellaneous Deductions. For a
Medical Reimbursement the agency must provide BOSP with the proper documentation. Salary
Refund documentation should be made available to BOSP upon request. In the event that agencies
should need to use a Recovery of State Funds deduction code specific to their agency an extra
Miscellaneous Deduction field has been provided. Enter the Deduction code number and name.

Beneficiary: A beneficiary section has been provided. A dropdown box will appear in the blank
cell beside each beneficiary type except for the # of Children. Each dropdown box contains a check
mark (√). Indicate who the beneficiary or beneficiaries will be by placing a check mark in the
appropriate box with the exception of the # of Children. The actual number of children who are
designated as beneficiaries should be entered into the cell beside # of Children. If only one child is
a beneficiary then place a check mark in the cell beside child. There is no need to place anything in
the blank cell beside # of Children.

Section 222.15 of the Florida Statutes specifies the order of eligibility of the beneficiaries.
“Pursuant to Section 222.15 of the Florida Statutes, wages and travel expenses due a deceased
employee are authorized to be paid to the spouse. If there is no spouse, then children of the
deceased over the age of 18 may receive the payment. If there are no children over the age of
18, wages and travel expenses may be paid to the father or mother of the deceased employee.
If there are no surviving parents, wages and travel expenses due upon death of an employee
may be paid to the administrator or personal representative of the deceased employee’s
estate”.

Page 8 of 9
BENEFICIARY CJIP PAYOUT INFORMATION: This section of the form calculates CJIP
Monthly pay by figuring an employee’s daily rate of pay and multiplying that by the number of
days worked and not the hourly rate of pay as was calculated in the Hourly Rate of Pay Calculation
With/Without CJIP. An employee who works a whole day or an hour of a day will be entitled to a
full day of CJIP Pay. The employee must be in active "pay status". There are several dropdown
boxes in this section. The blank cell under CJIP PAY AMOUNT contains a list of amounts that an
employee may receive ranging from $20.00 to $130.00 per month. In the blank cell under the PAY
MONTH there is a list of Months and the number of days in that month. Dates in this field range
from January of 2011 through December of 2014. In the blank cell under the DAYS OF MONTH
the dropdown box provides a list of the common number of days in the month (i.e. 20, 21, 22, and
23). The HOURS WORKED section of the worksheet must be entered by the preparer. DAILY
RATE OF PAY and GROSS fields will automatically populate. Two CJIP payment lines have
been provided in the event that the employee should receive two payments.

BUREAU OF STATE PAYROLLS USE ONLY

This section of the form is only to be completed by BOSP.

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