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New Employee Information

Appointment Forms for New Hires United States District Court
for the Western District of Pennsylvania

Joseph F. Weis, Jr.
U.S. Courthouse
700 Grant Street
Pittsburgh, PA 15219

Michelle Tambellini, Human Resources Manager
michelle_tambellini@pawd.uscourts.gov
(412) 208-7536

Karen Jones, Human Resources Specialist
karen_ann_jones@pawd.uscourts.gov
(412) 208-7537

 


Below please find information regarding fingerprinting, background checks, required identification, and benefits as well as appointment forms for your completion. Please review this information carefully, and complete all required forms.

The majority of the forms are Adobe Acrobat PDF forms, and should be completed on your p.c. Hand‐written forms are strongly discouraged. We recommend that you save all forms to your p.c. so that you can easily make changes if necessary. Print each form as you complete it, and sign where indicated. Please do not print or submit instruction pages. Please scan and email your completed forms to Michelle or Karen at the email address above. In order to avoid any delay in processing your pay, we ask that you come in for an initial meeting after you've completed your forms and prior to your start date. We will complete any remaining paperwork, verify your ID, complete your fingerprinting, and take your photo for your Court ID card at this time. Please contact us as soon as possible to arrange a date and time for our meeting. If you have any questions, please don't hesitate to contact us.

Appointment Forms
Below you will find links to various appointment forms for your completion. Unless designated as “optional” all forms are required to be completed to begin your employment with the court. Detailed instructions are included on how to complete each form.


Forms Index

1. Application For Judicial Branch Federal Employment (A0‐78)
2. Race/Ethnicity, Gender, & Disability Identification
3. Identification/Employment Eligibility Verification (Form I‐9)

4. Residency Certification Form for Local Earned Income Tax Withholding (CLGS‐32‐6)
5. FastStart Direct Deposit Form (FMS‐2231)

6. Employee's Federal Withholding Allowance Certificate (W4)
7. State Tax Withholding
8. Fingerprinting/Background Check
9. Personal Information Form
10. Health Benefits Election Form (SF 2809)
11. Life Insurance Election Form (SF 2817)
12. Designation of Beneficiary Form ‐FEGLI (SF‐2823)
13. Designation of Beneficiary Form – Unpaid Compensation (SF ‐1152)

14. Designation of Beneficiary Form - FERS (SF-3102)
15. Designation of Beneficiary Form - FERS (TSP-3)

 


1. Application For Judicial Branch Federal Employment (A0‐78)
http://www.uscourts.gov/uscourts/FormsAndFees/Forms/AO078.pdf

Complete this form accurately and entirely, as it is an important record of prior experience used to determine your qualifications and may be used in future consideration of opportunities for advancement. Current address should be the address you will be residing at during your employment. Under the Work Experience section, begin with your most recent position and work back in time. Be sure to include the month‐day‐year of employment and number of hours worked per week. Also include all legal experience (paid, unpaid or as a volunteer) after obtaining your JD, and we must have your exact date of receiving JD (month-day-year).

2. Race/Ethnicity, Gender, & Disability Identification
Voluntary Identification Form

You are requested to provide this information to aid the federal judiciary in reporting on equal employment opportunities. This information will be used in planning and monitoring fair employment practices programs.

3. Identification/Employment Eligibility Verification (Form I‐9)
http://www.uscis.gov/sites/default/files/files/form/i-9.pdf

Form I‐9 has been provided to you in order to verify your eligibility for employment with the U.S. Courts. Please complete Section 1 of this form. You are required to bring proper identification on the day you meet with personnel prior to the date of your employment. Please review the Lists of Acceptable Documents on the last page of the Employment Eligibility (I‐9) Form for accepted forms of identification. Your identification must be current; expired identification will not be accepted. Please note that you must provide either one form of identification from List A or two forms of identification: one from List B and another from List C.

4. Residency Certification Form for Local Earned Income Tax Withholding (CLGS‐32‐6)
This form is required for all employees who will be working in Pennsylvania. Complete one of the below forms based on where you live and where you will be working. Please leave the gray areas blank. Complete the Employee Information and Certification sections.

PA residents working in Pittsburgh should complete the below form:
Res Cert Pittsburgh

PA residents working in Erie should complete the below form:
Res Cert Erie

PA residents working in Johnstown should complete the below form:
Res Cert Johnstown

PA residents working in Duncansville should complete the below form:
Res Cert Duncansville

5. FastStart Direct Deposit Form (FMS‐2231)
https://www.fiscal.treasury.gov/fsservices/gov/pmt/eft/2231.pdf

Direct Deposit is mandatory for all government employees. Follow the instructions provided on page two of the form. The last digit of your Routing Transit Number goes in the “Check Digit” field. Please enter your Social Security Number in the “Employee Payroll Identification Number” space. Consult your bank if you need assistance completing this form.

6. Employee's Federal Withholding Allowance Certificate (W4)
http://www.irs.gov/pub/irs-pdf/fw4.pdf

*IMPORTANT NOTE* The address entered on the W‐4 is the “address of record” used for mailing the W‐2 at the end of the year and for other benefit mailing purposes. If an out of state address is listed on this form, withholdings for that state may apply (in addition to PA withholdings). Complete the first page of this form to withhold the correct amount of federal income tax from your pay. Please complete the worksheet or consult an accountant or tax preparer for advice on the number of allowances you should claim.

7. State Tax Withholding
You will have PA Income Tax withheld from your pay.

PA Residents: No form is required. Pennsylvania state tax is based on a flat tax rate of 3.07%. There are no allowances based on the number of dependents claimed, marital status, age, etc.

8. Fingerprinting/Background Check
Finger printing Document 
http://www.uscourts.gov/HR/Background_Check_FAQs.pdf

Please note that as a condition of employment, a background check, including fingerprinting, is now mandatory for all new employees who are appointed to positions in the federal courts. Please complete the above Fingerprint Information Sheet. The information collected on this form is required to be forwarded with your fingerprints for purposes of requesting your background check. You will be hired provisionally, pending the outcome of the background check. You will be fingerprinted during the initial meeting with Personnel, which said meeting must be scheduled before your first day. A link to frequently asked questions regarding background checks is also included above.

9. Personal Information Form
COOPinfosheet.pdf 

The information requested in this form is for use in an emergency situation.

10. Health Benefits Election Form (SF 2809)
To view available plans, please visit the Office of Personnel Management (OPM) website. This site offers reference materials and a comparison tool to assist employees with choosing a health plan that best meets their needs.
https://www.opm.gov/healthcare-insurance/healthcare/plan-information/plans/2020/state/pa

http://www.opm.gov/forms/pdf_fill/sf2809.pdf
When completing the enrollment form, you have to scroll through several pages of instructions before you reach the Health Benefits election form. Complete only part A and C if you wish to enroll. You may enter the Plan name and Enrollment code. At your initial meeting with Personnel, we will complete the remainder of the form including securing your signature and date.

Your option to enroll in a health care plan is limited to 60 days from your start date. The earliest your health benefits can be made effective is the first Monday of the pay period that begins AFTER your start date, and after you submit your enrollment form. Since the judiciary uses biweekly pay periods, it could be up to two weeks before your health benefits are effective, depending on your start date. Once you make your election it can NOT be changed, so please carefully consider your options when making your selection.

You will only be able to make changes during the annual Open Season (November to early December) or if you experience a qualifying life event such as marriage or birth of a child. The Federal Employee Health Benefits (FEHB) program offers different types of health plans, including fee-for-service, HMO's, and high deductible plans which offer a Health Savings Account component. Please note that if you enroll in a plan with a Health Savings Account or are covered by a Health Savings account through a family member or otherwise, you are NOT eligible to elect a Health Care Reimbursement Account under the Judiciary's Flexible Benefit Program. An individual is not permitted to have a Health Savings Account and a Health Care Reimbursement Account at the same time.

11. Life Insurance Election Form (SF 2817)
For information on the life insurance program, please review the attached brochure.
http://www.opm.gov/healthcare-insurance/life-insurance/reference-materials/federalbooklet.pdf

Additional information may also be found at:
http://www.opm.gov/healthcare-insurance/life-insurance/

http://www.opm.gov/Forms/pdf_fill/SF2817.pdf
Submit page one only. Information on Federal Employees' Group Life Insurance (FEGLI) is available at http://www.opm.gov/healthcare‐insurance/life‐insurance . To determine the value of your coverage and calculate premiums, visit the FEGLI Calculator.

Unless you waive coverage, you will be automatically enrolled in the Basic Life Insurance Plan effective on your start date, and deductions will be taken directly from your pay to cover the cost of this plan. You must complete the Life Insurance Election Form to indicate whether you wish to waive coverage, elect basic coverage, or elect optional coverage in addition to basic.

You will have 60 days to elect additional Optional coverage. To waive coverage and avoid deductions to your paycheck, complete the Election Form and return to Personnel during your initial meeting or before the end of your first pay period. If you do waive coverage, there is a one year minimum waiting period from the date of the signed waiver, and you must provide satisfactory medical evidence of insurability before re‐enrolling.

12. Designation of Beneficiary Form ‐FEGLI (SF‐2823) (optional)
http://www.opm.gov/forms/pdf_fill/sf2823.pdf

If you elect life insurance coverage, please complete a Designation of Beneficiary Form (SF‐2823). Two witnesses are required. Forms may not contain corrections of any kind (scratch outs, whiteout, etc).

13. Designation of Beneficiary Form – Unpaid Compensation (SF ‐1152) (optional)
http://www.opm.gov/forms/pdf_fill/SF1152.pdf

For completion by all employees. Beneficiaries receive monies not yet received by the employee, such as unpaid salary and lump sum annual leave payments. Please enter your name and home address in the box at the bottom of the form. Two witnesses are required. Forms may not contain corrections of any kind (scratch outs, whiteout, etc).

14. Designation of Beneficiary Form - FERS (SF-3102) (optional) (career employees only)
http://jnet.ao.dcn/resources/forms/designation-beneficiary-fers

For completion for career employees only. This form is used to designate the beneficiary(ies) for any Federal Employees Retirement System (FERS) lump-sum benefits payments. If designation of beneficiary forms are not completed and on file, benefits are paid according to the order of precedence which is listed on the form, unless there is a court order in effect that would require payment to another person(sTwo witnesses are required. Forms may not contain corrections of any kind (scratch outs, whiteout, etc).

15. Designation of Beneficiary Form - FERS (TSP-3) (optional) (career employees only)
https://www.tsp.gov/forms/civilianForms.html

For completion for career employees only. This form is used to designate the beneficiary(ies) for any Thrift Savings Plan (TSP) benefits payments. If designation of beneficiary forms are not completed and on file, benefits are paid according to the order of precedence which is listed on the form, unless there is a court order in effect that would require payment to another person(s) One witness is required. Forms may not contain corrections of any kind (scratch outs, whiteout, etc).

Supplemental Benefits

Forms for enrolling in the following supplemental benefits are not provided in this document. Instructions for enrolling in supplemental benefits will be provided during your initial meeting with Personnel. Please see the links provided below for additional information. After your start date, you will also receive a packet in the mail directly from the third party administrator of these plans. Note that most of these benefits allow for 60 days to elect.