Admin Forms

Human Resources

Customer Service
Employee Complaint Form
-Your Voice Your Thoughts English Version / Spanish Version

Insurance
20-21 Employee Benefits Program (Sonoma County)
20-21 Employee Benefits Program (Mendocino and Lake Counties)
USleb: Free Mobile Benefits App
Medicare Prescription Drug Coverage 2019
2014 Health Reimbursement Arrangement Welcome Packet
-Participant Quick Start Guide
Submit Your Claim Receipt (Open in Google Chrome-
https://ebsbenefits.lh1ondemand.com)

There are a few ways to get reimbursed:

• Follow the hyperlink on the first page of the Welcome Packet. You will fill out your info, and attach scanned copies of your receipts.
• Print and fill out the second page (it can be mailed or faxed, but faxing should have the quickest turnaround.)
• Download the EBS app.

Logging in the first time will be your first initial, last name, and last 4 of your ssn.

Employment
Consumer Action Form
Employment Application Form
Personnel Action Form (PAF) 2018 Instructions
Personnel Requisition Form (PRF) 2018  Instructions
Resignation Notice

Payroll
Authorization for Direct Deposit
DE4 2021
– Exempt Exception Form
Meal Period Waiver
Overtime Approval
Time Off Request
Timesheet for Regular Employees
W-4 Form
Unpaid Time Off Request