Form Dfs K4 1055 PDF Details

For many firefighters in Florida, staying informed about the necessary paperwork and procedures specific to their profession is crucial, especially when changes occur in their employment status. Among the array of forms they may encounter, the Dfs K4 1055 form serves a significant function within the Florida Department of Financial Services, under the Division of the State Fire Marshal. Designed as a Notice of Ineligibility under the Firefighters Supplemental Compensation Program, it is a critical document for firefighters undergoing transitions such as transfer, reclassification, termination of employment, leave of absence, or suspension—in or without the pay scenario. This form becomes imperative to fill out for maintaining accurate records and ensuring compliance with the program's requirements. By providing details like the firefighter’s name, social security number (optional for better assistance), contact information, alongside the fire department's details and the reason for the change in eligibility status, this form must be submitted by the employing agency to the Bureau of Fire Standards & Training within ten business days of the ineligibility event. This ensures that the firefighters' supplemental compensation adjustments are made accurately and in a timely manner, reflecting any changes in their employment status correctly.

QuestionAnswer
Form NameForm Dfs K4 1055
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesform dfs k4 1055, FIANCIAL, NW, GAINESVILLE

Form Preview Example

THE DEPARTMENT OF FIANCIAL SERVICES

Division of the State Fire MarshalAction may be completed at www.floridastatefirecollege.org

FIREFIGHTERS SUPPLEMENTAL COMPENSATION PROGRAM

NOTICE OF INELIGIBILITY

BUREAU OF FIRE STANDARDS & TRAINING

Please type or print requested information legibly.

NAME OF FIREFIGHTER: LAST

FIRST

M.I.

MAIDEN NAME (If applicable)

 

 

 

 

 

 

 

HOME ADDRESS

CITY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

SOCIAL SECURITY NUMBER1

 

 

 

 

 

TELEPHONE #

 

 

 

 

 

 

 

NAME OF FIRE DEPARTMENT

 

 

 

 

 

 

 

 

 

 

 

 

FIRE CHIEF/AUTHORIZED AGENT

 

 

 

 

DEPARTMENT TELEPHONE #

 

 

 

 

 

 

 

DEPARTMENT MAILING ADDRESS

CITY

 

 

 

STATE

ZIP CODE

Reason for Change in Eligibility Status:

Transferred or Reclassified

(no longer serving as a full-time firefighter)

Employment Terminated

Leave of Absence

(without pay)

Suspended Suspended

(without pay)

Date of Ineligibility:

(FIRST DAY OF INELIGIBILITY, NOT LAST WORKING DAY)

PLEASE BE SURE TO SUBMIT THE REQUIRED NOTICE OF TERMINATION FORM DFS-K4-1033

SIGNATURE OF FIRE CHIEF OR AUTHORIZED AGENT

DATE

NOTE: THIS FORM IS TO BE SUBMITTED BY THE EMPLOYING AGENCY WITHIN

TEN (10) BUSINESS DAYS OF INELIGIBILITY TO THE:

BUREAU OF FIRE STANDARDS & TRAINING

11655 NW GAINESVILLE ROAD, OCALA, FLORIDA 34482-1486

01

07

02

08

03

09

Bureau Use Only

04

10

Effective Date:

05

06

11

12

Recorded by:

 

Date:

1Please note that the social security number is not required; however, if you provide it, it will greatly assist us in assisting you.

DFS-K4-1055 REV 03/06

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