This is the electronic form used to request reimbursement for Staff Development/Wellness benefits. You must have an electronic receipt to attach to the eForm in order to submit. For more information on eligible/ineligible items, and maximum amounts go to http://sonomacounty.ca.gov/HR/Benefits/Staff-Development/

Staff Development / Wellness Reimbursement Request

* = Required Field

Employee ID # Value is not selected

Clear

Employee First Name

Employee Last Name

Department

Employee Email

Day Phone

Bargaining Unit #

FTE

Title

(Does not include pending claims) Staff Development Available Balance

Complete all applicable boxes below

Item 1

We prefer that you group recurring purchases as a single item for eForm purposes. For example, monthly gym dues for July 2019 through December 2019 can be entered in Item 1. In the Description enter “Gym dues July 2019-December” in the Date Purchased field “07/01/2019”.

You may enter up to five items on this eForm as long as the receipts are dated in the same fiscal year.

1. What Category of Staff Development is this item? Value is not selected

1. Purchase Date

1. Amount Paid Before Taxes

1. Sales Taxes Paid on the Item

1. Amount Paid Plus Taxes Paid

1. Travel out of county?

Yes

No

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement.

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement. Without a Travel Authorization Form, the item will be reimbursed as taxable unless the Employee Description of Expenses clearly explains how the cost is directly related to your job class.

1. Requires Upload of Travel Authorization

1. Employee Description of Expenses

1. Course Name

1. Location

1. From Date

1. To Date

1. Amount Requested

Add another item? Value is not selected

Item 2

2. What Category of Staff Development is this item? Value is not selected

2. Purchase Date

2. Amount Paid Before Taxes

2. Sales Taxes Paid on the Item

2. Amount Paid Plus Taxes Paid

2. Travel out of county?

Yes

No

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement.

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement. Without a Travel Authorization Form, the item will be reimbursed as taxable unless the Employee Description of Expenses clearly explains how the cost is directly related to your job class.

2. Requires Upload of Travel Authorization

2. Employee Description of Expenses

2. Course Name

2. Location

2. From Date

2. To Date

2. Amount Requested

Add another item? Value is not selected

Item 3

3. What Category of Staff Development is this item? Value is not selected

3. Purchase Date

3. Amount Paid Before Taxes

3. Sales Taxes Paid on the Item

3. Amount Paid Plus Taxes Paid

3. Travel out of county?

Yes

No

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement.

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement. Without a Travel Authorization Form, the item will be reimbursed as taxable unless the Employee Description of Expenses clearly explains how the cost is directly related to your job class.

3. Requires Upload of Travel Authorization

3. Employee Description of Expenses

3. Course Name

3. Location

3. From Date

3. To Date

3. Amount Requested

Add another item? Value is not selected

Item 4

4. What Category of Staff Development is this item? Value is not selected

4. Purchase Date

4. Amount Paid Before Taxes

4. Sales Taxes Paid on the Item

4. Amount Paid Plus Taxes Paid

4. Travel out of county?

Yes

No

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement.

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement. Without a Travel Authorization Form, the item will be reimbursed as taxable unless the Employee Description of Expenses clearly explains how the cost is directly related to your job class.

4. Requires Upload of Travel Authorization

4. Employee Description of Expenses

4. Course Name

4. Location

4. From Date

4. To Date

4. Amount Requested

Add another item? Value is not selected

Item 5

5. What Category of Staff Development is this item? Value is not selected

5. Purchase Date

5. Amount Paid Before Taxes

5. Sales Taxes Paid on the Item

5. Amount Paid Plus Taxes Paid

5. Travel out of county?

Yes

No

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement.

Attaching the Travel Authorization Form helps indicate to HR approvers, that there were appropriate approvals to evidence that the cost was directly job related and is a non-taxable reimbursement. Without a Travel Authorization Form, the item will be reimbursed as taxable unless the Employee Description of Expenses clearly explains how the cost is directly related to your job class.

5. Requires Upload of Travel Authorization

5. Employee Description of Expenses

5. Course Name

5. Location

5. From Date

5. To Date

5. Amount Requested

Total

Total Amount Paid

Total Amount Requested

Upload Receipts or Relevant Files

Upload telework agreement

By selecting this box I acknowledge that my reimbursement may be subject to income tax as described in the Staff Development/Wellness Benefit Allowance program guidelines found here: http://sonomacounty.ca.gov/HR/Benefits/Staff-Development/

I acknowledge

Job related:

CEUs
Professional Memberships and Dues
Conference
Class
Course
Workshop
Travel Expenses
Parking Fees
Mileage Reimbursement
Lodging
Meals

Not Job related:

Education Conference
Class
Course
Workshop
Certifications
Travel Expenses
Mileage Reimbursement

Wellness Expenses:

Parks Pass
County Gym
Gym Dues
Gym Equipment
Sport Entry Fees
Sporting Lessons and Equipment
Exercise Equipment
Diet Management Programs
Nutrition Classes
Classes for Health Promotion / Fitness
Weight Loss Coaching
Personal Exercise Coaching
Exercise Programs
Stress reduction massage or therapy
Excercise Videos or DVDs
Book/Periodical/Journal
Health trackers, step counters and smartwatches such as Fitbits and Apple Watches

Computer and Mobile:

Desktops
Laptops
Cell Phones
Smart Phones
Tablets
Software Applications

(Note: DSA BU 46 and 47 has a 50% of annual Allowance limit on desktop and laptop computers (no limit on mobile phones)

SCDPDAA and SCPA Educational/Training:

Professional development expenses, i.e. membership dues, conference and training fees, books, legal manuals.

Tool Allowance for Local 39 only:

Tools
Tool Replacement

Job Required:

Professional Licenses
Certifications
Fee payments related to a Class A or Class B commercial driver license.

Approved emergency preparedness items are limited to the following:

Portable generators and emergency power battery systems (equipment costs only)
Personal and family pre-configured emergency/disaster/first aid kits (Purchased as a unit)
Hand crank radios
National Oceanic and Atmospheric (NOAA) weather radios

Specific exclusions include but are not limited to the following:

Clothing
Disposable batteries
Electrical installation
Equipment warranties, repair or service costs
Extension cords
Individual items intended as a “build it yourself” emergency kit
Medical supplies
Provisions for pets or animals
Temporary living structures such as tents or trailers
Transportation
Two-way radios
Water purification systems
Weapons

Ergonomic Office Expenses:

Cushions for office chair seat, lumbar support, and armrest
Ergonomic document holders
Footrests
Laptop stands
Lap desks
Monitor risers
Office chairs
Office desks
Wrist pad for keyboard and mouse

REQUIREMENT: Employees must attach approved telework agreement for each eForm claim submission.

PLEASE NOTE: In the event the equipment is needed as part of a reasonable accommodation in conjunction with a documented work restriction, please discuss the need with your HR Liaison prior to making the purchase and seeking reimbursement.

Your total amount requested exceeds your staff development available balance

Amount Requested with Currency Symbol

Difference of Amount Available and Amount Requested

Employee ID # (Access DB) Value is not selected

Your session has timed out.

Click here to access the application.

Staff Development / Wellness Reimbursement Request (SCWA and HSD) v1.3

Staff Development / Wellness Reimbursement Request

Item 1

Item 2

Item 3

Item 4

Item 5

Total