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UNIVERSITY OF CALIFORNIA
PERMANENT INTERLOCATION TRANSFER
TERMINATING LOCATION - EMPLOYEE DATA SHEET
UFIN 301 (R03/16)
TRANSFERRING
FROM:
TO:
EMPLOYEE NAME (LAST, FIRST, MI)
LAST PAY DATE
8233 EXP DATE
Print Form
EFFECTIVE DATE:
SOCIAL SECURITY NUMBER
HIRE DATE
ORIGINAL HIRE DATE
COUNTRY OF RES
CIT
VISA
BIRTH DATE
OATH DATE
EAD
RET SYS
I-9 DATE
OASDI/MED
Sex
VAC HRS
PRIOR SERV MOS
SICK HRS
M
F
AS OF
SERV CR MOS
OASDI COVERED GROSS*
CAREER HOURS
MEDICARE COVERED GROSS*
TRANSFERRING OASDI/MED LIABILITY TO NEW LOCATION
BEN HRS
SECONDARY BELI STATUS QUALIFICATION CODE
Yes
RET. COVERED GROSS
No
IF NO, PROVIDE REASON:
SAFE HARBOR GROSS
UCRP FISCAL YTD COV. COMP
COVERED COMP. LIMIT CODE
ENROLLED
BENEFITS
G
MCB CUR/NXT $
MEDICAL
DENTAL
N
/
PLAN NAME
D1
ENROLLED DEPENDENT INFORMATION
D3
COV CODE
COVERED THROUGH **
COV CODE
COVERED THROUGH **
VISION
PLAN NAME
COV CODE
COVERED THROUGH **
LEGAL
PLAN NAME
COV CODE
COVERED THROUGH **
COV CODE
COVERED THROUGH **
STATE DOMESTIC
PARTNERS FORM
YES
SUPPLEMENTAL
LIFE
PLAN CODE
DEPENDENT LIFE
PLAN CODE
NO
ANNUAL SALARY
ANNUAL SALARY
EFFECTIVE DATE ***
MO SALARY
EFFECTIVE DATE ***
AD&D
COVERAGE CODE
PRIN SUM
EFFECTIVE DATE ***
HEALTH HSA
RELATION
SSN
OTHER DEDUCTIONS ****
WAITING PERIOD
HEALTH FSA
DOB
EFFECTIVE DATE ***
SUPPLEMENTAL
DISABILITY
DEPCARE FSA
NAME
ANNUAL AMT
DECLINING BAL
MONTHLY AMT
YTD AMT
EFF DATE
TERM DATE
ANNUAL AMT
DECLINING BAL
MONTHLY AMT
YTD AMT
EFF DATE
TERM DATE
DESCRIPTION
DED. AMT.
SPECIAL COMMENTS
MONTHLY AMT
403(B) MAC GTN 008 ****
457(B) MAC GTN 398 ****
PREPARED BY:
UCRP BUYBACK GTN 029
DED AMT
DECLINING BAL
403(B) ST LOAN
DED AMT
DECLINING BAL
403(B) LT LOAN
DED AMT
DECLINING BAL
*
**
***
****
EMAIL ADDRESS:
PHONE:
IF TRANSFERRING TO LBL OR HASTINGS, FICA GROSSES RESTART.
DATE COVERAGE ENDS AT "TRANSFERRING FROM" LOCATION.
THE TERMINATING LOCATION SHOULD PROVIDE THE EFFECTIVE DATE FOUND ON THE IINS SCREEN.
AFTER TAX, UNION DUES, SALARY ATTACHMENTS, TAX LEVIES, OTHER STATE TAX (ATTACH UPAY 830).
RETN: ACCOUNTING: 5 YEARS AFTER SEPARATION EXCEPT IN CASES OF DISABILITY, RETIREMENT, OR DISCIPLINARY ACTION, IN WHICH CASE RETAIN UNTIL AGE 70.
DATE:
M D
V
L
Instructions for Completion of UFIN 301: Permanent Interlocation Transfer
To ensure vacation and sick leave balances, UCRP service credit, retirement savings program and other benefits information transfer properly, the UFIN 301 should be prepared in a
timely manner. Locations may wish to complete the non-shaded fields and forward to the receiving location. The solid shaded fields can be completed once the final payment has
posted and all final balances are known. Benefit representatives at both locations should coordinate and work closely with each other and the employee. Transferring employees do not
have a PIE as a result of the transfer; in general, current benefits continue at the new location. Any changes are normally done at the next Open Enrollment.
Definitions:
Last Pay Date: Enter the last date for which the employee will be paid on the transferring (separating) campus
Original Hire Date: Should reflect the first date of employment with the University of California. This date can be obtained from the EPER screen in PPS.
Hire date: If the personnel action was a transfer (without a break in service) from another UC campus, the hire date should reflect the most recent date of continuous employment
with the University of California. An incorrect date may have retirement derivation implications.
Both the original hire date and the date of hire must be completed. In most cases, they will be the same date. However, if there has been a break in service, the hire date would be
different from the original hire date.
 Example 1: employee A starts at the Irvine campus on 1/1/2005. This is the original date of hire. Then on 2/9/14 employee leaves Irvine and on 2/10/14 starts at Riverside.
Because there has been no break in service, the hire date at the Riverside Campus should be 1/1/2005.
 Example 2: employee A originally started at Irvine on 1/1/2005. This is entered as the original date of hire. On 2/9/14, employee A terminates employment with the Irvine campus.
On 4/1/14, employee A is hired at Riverside. The employee was hired after the 1st day of the second month. 4/1/14 is entered as the "hire date" and the employee is in the new
retirement tier.
Note: In example 2 above, because the employee was not rehired by the 1st day of the second month after separation date, they are in the 2013 retirement tier. However, had the
employee been rehired on 3/31/14 at Riverside, then they would have had 3/31/14 as the "hire date" and they would remain in the 1976 retirement tier.
Country of Res: Enter the country of residence (IALN).
Ret Sys: Enter `U' for UCRP (1976 tier), `W' for UCRP (2013 tier), `H' for Safe Harbor, `B' for two tier or `N' for not contributing (IGEN)
OASDI/Med: Enter `E' for OASDI and Medicare, `M' for Medicare Only and `N' for not contributing to either OASDI or Medicare (IGEN)
Prior Serv: Enter prior service months (IPER)
Serv Cr: Enter service credit from date (IHR2)
Ben Hrs: Enter hours towards benefits eligibility (IHR2)
Secondary BELI Status Qualification Code: Enter 52 (EPER)
Career Hrs: Enter hours towards career eligibility (IHR2)
EAD: employment authorization document authorizes an alien to work in the U.S. for a period of time.
8233 Exp Date: refers to the tax treaty document and expiration of tax treaty benefits for a foreign national.
Citizenship code: Captured to assist in the determination of tax residency for tax withholding purposes only and should not be used for any other purpose.
Visa: Used for determining the tax residency for tax withholding.
I-9 Form: A copy of the original is transmitted with the UFIN301. If the receiving location notices the I-9 is incomplete or deficient it is advisable to take steps to correct the form.
OATH Date: Date the State Oath was signed or an amended version re-signed.
Things that should be done to assist the employee: The benefits representative or the responsible person should advise the employee of the benefits and accruals that will be
transferred. It is the transferring campus administrator's responsibility to complete the Interlocation Transfer form (UFIN301) and to transmit it securely to the receiving campus.
Medical & Dental Benefits: Employees terminating at sending campus with IT reason code will have coverage through the month following the separation month. The receiving campus
should verify that the employee can continue in the same medical plan since availability can vary by location. If the employee's plan is not available in their new location, the employee
may enroll in a new plan. If the employee is enrolled in a medical plan with a service area and/or DeltaCare USA, the employee may need to change the primary care physician and/or
dentist. The employee may receive a COBRA packet for continuing health benefits. You can inform the employee to disregard that information since benefits should continue at the new
location.
Flexible Spending Accounts (FSA, Health and DepCare): When an employee transfers to a new UC location, participation in the flexible spending account plans remain at the same
contribution level. If any monthly contributions were missed due to payroll deadlines, the new location must make a retroactive adjustment so that coverage and contributions are
continuous. The transferring campus should delete the FSA end date on the ERET screen to ensure that the spending card is not disabled as a result of the separation date being
transmitted to Conexis.
Health Savings Account (HSA): Assume the employer contribution to HSA has already been made by the sending campus. Only the employee monthly deduction needs to be
established at the receiving campus. Employees are allowed to change their monthly deduction at any time.
403(b) and 457(b) Plans: If the employee is contributing to the 403(b), the 457(b) or the DC After-Tax plans, the employee will need to redo the contribution election for the new
location. Refer the employee to Fidelity Retirement Services (netbenefits.com or 866-682-7787). Deferral elections are subject to payroll deadlines so contributions may be missed.
Maximum annual contribution information should be transmitted from the departing campus to the receiving campus to assure that the employee does not inadvertently over-contribute to
the tax-deferred savings plans. Hiring campuses should pay attention to, compare, and overwrite (when necessary) the assigned MAC on the ECEN screen in situations where the
transferring employee will be 50 years or over as of the end of the calendar year of original hire. To ensure that any existing 403(b) loan repayments continue, coordination with the
departing campus and/or Fidelity Retirement Services may be necessary.

It is recommended to attach the final pay advice to verify HSA, FSA, DepCare, etc. as well as relevant screen shots from PPS to support the entries.
For further information see Accounting Manual Chapter on Interlocation Transfers: http://policy.ucop.edu/doc/3410266/AM-P196-38
PRIVACY NOTIFICATIONS
STATE
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following information to individuals who are asked to supply
information about themselves.
The principal purpose for requesting information on this form, including your Social Security number, is to verify your identity, and/or for benefits administration, and/or for federal and
state income tax reporting. University policy and state and federal statutes authorize the maintenance of this information.
Furnishing all information requested on this form is mandatory. Failure to provide such information will delay or may even prevent completion of the action for which the form is being
filled out. Information furnished on this form may be transmitted to the federal and state governments when required by law.
Individuals have the right to review their own records in accordance with University personnel policy and collective bargaining agreements. Information on applicable policies and
agreements can be obtained from campus or Office of the President Staff and Academic Personnel Offices.
The official responsible for maintaining the information contained on this form is the Vice President - University of California Human Resources, 1111 Franklin Street, Oakland, CA
94607-5200.
FEDERAL
Pursuant to the Federal Privacy Act of 1974, you are hereby notified that disclosure of your Social Security number is mandatory. The University's record keeping system was
established prior to January 1, 1975 under the authority of The Regents of the University of California under Article IX, Section 9 of the California Constitution. The principal uses of your
Social Security number shall be for state tax and federal income tax (under Internal Revenue Code sections 6011, 6051 and 6059) reporting, and/or for benefits administration, and/or to
verify your identity.