Parental Consent to Employment of a Minor
I am a parent or legal guardian of the minor child: ___________________________.
Child’s date of birth: _________________________.
I consent to my child’s employment as (position title)
_______________________________ at the following work location:
________________________________ (name of business). I have familiarized myself
with the nature of the work my child will be doing, and I consent to such
employment.
I have reviewed all new employee paperwork with my child, including the attached
employee agreement which includes an agreement to submit all disputes to final and
binding arbitration in lieu of litigating claims in court. I agree that all claims related
to my child’s employment will be resolved under the terms of the Employer Flexible
Solutions Plan, whether such claims are brought in my child’s name or in the name of
a parent or guardian on behalf of the minor.
I consent to the employment agreement, and authorize and ratify my child’s signature
on all employment related documents.
Date: __________________
________________________________________
Signature of Parent/Legal Guardian
________________________________________
Printed Name of Parent/Legal Guardian
___________________________
Telephone of parent/guardian
____________________________
Email address for parent/legal guardian:
_________________________________________________________
Mailing address of parent/legal guardian
New Hire Packet Checklist
Company Name: _________________________________________
Employee Name: _____________________________ Hire Date: ___________
Submitted to Employer Flexible Date: __________
U
To Be Completed by Hiring Manager:
□
New Employee Payroll Data Form
□
Employee Job Category
□
Form I-9, Section 2
(Review and verification of documents for work eligibility must be
completed by client designee within 3 business days of employee’s first day of employment. Do
not send copies of identification to Employer Flexible.)
U
To Be Completed by Employee:
□
New Employee Data Form
□
Employment Agreement
□
Background Check Disclosure and Consent
□
Direct Deposit Form
□
Acknowledgement of Company or Orientation Handbook
□
Employee Acknowledgement of Workers’ Compensation Network (Texas Only)
□
Wage Deduction Authorization Agreement
□
Form W-4
□
Form I-9, Section 1
(Employee must complete no later than the first day of employment.)
U
Employee Received and Retained:
□
Orientation or Company Employee Handbook
Submission Instructions
Please Complete and Return this
to Human Resources
Via email at: HUhr@employerflexible.com
Or via fax: 281-377-7459
Must Be Submitted
5 Days
Prior to 1
st
Payroll
Employer Flexible HR, LLC © Copyright 201, All rights reserved
NEW EMPLOYEE PAYROLL DATA FORM
Directions:
On the date of hire, the On-site HR Rep completes this form for the new employee.
Employee Name: First
□ Mr. □ Mrs.
□ Ms. □ Dr.
Middle
Last
Last 4 Digits
of Soc. Sec. No.:
Original Hire Date:
Employee Position Category: (Check only one.)
Client Name:
Position Title:
Department:
Location / Division:
Employee Work State:
Work Address: Street
City
State
Zip Code
Work Phone Number:
Work Fax Number:
Work Email:
Classification
□ Full-time Regular
(≥ 30 hours)
□ Full-time Temp.
□ Part-time Regular
(< 30 hours)
□ Part-time Temp.
Is the employee part of a collective bargaining unit or
union? □ Yes □ No
Is this employee a
supervisor? □ Yes □ No
Is the employee a sole proprietor, partner in a
partnership, or more than 2% stakeholder in an
S-corporation? □ Yes □ No
Is the employee exempt
from overtime?
□ Yes □ No
Pay Rate
□ Hour
□ $ _____________ / Pay Rate is Per □ Year
□ Other ___________
□ Commission
□ Draw against Commission in lieu of salary
Amount: $ ___________ / Pay Rate is Per _____________
Employee Reports to:
Sub-Classification
□ Intern/Seasonal
□ Leave of Absence
Pay Frequency:
□ Weekly 52/40
□ Bi-Weekly – 26 / 80
□ Semi-Monthly 24/ 86.67
□ Monthly – 12 / 173.33
Comments: (Special circumstances such as additional vacation allowance.)
Client Designee Signature:
Client Designee Printed Name:
Date:
Employer Flexible HR, LLC © Copyright 201, All rights reserved
EMPLOYEE JOB CATEGORY
(As identified by the EEOC. Check only one.)
□ Executive/Senior Level Officials and
Managers. Individuals who plan, direct and
formulate policies, set strategy and provide
the overall direction of enterprises or
organizations for the development and
delivery of products or services, within the
parameters approved by boards of directors
or other governing bodies. Residing in the
highest levels of organizations, these
executives plan, direct or coordinate
activities with the support of subordinate
executives and staff managers. (i.e.: In
larger organizations, those individuals
within two reporting levels of the CEO.
Examples of these kinds of managers are:
CEOs, COOs, CFOs, line of functional areas
or operating groups, CIOs, CHROs, CMOs,
CLOs, management directors and managing
partners.)
□ First/Mid Level Officials and Managers.
Individuals who serve as managers, other
than those who serve as Executive / Senior
Level Officials and Managers, including those
who oversee and direct the delivery of
products, services or functions at group,
regional or divisional levels of organizations.
These managers receive directions from the
Executive/Senior Level management and
typically lead major business units. They
implement policies, programs and directives
of executive/senior management through
subordinate managers and within the
parameters set by Executive/Senior Level
management. (i.e.: vice presidents and
directors, group, regional or divisional
controllers; treasurers; human Resources,
information systems, marketing, and
operations managers. The First/Mid Level
Officials and Managers sub- Category also
includes those who report directly to middle
managers. These individuals serve at
functional, line of business segment or
branch levels and are responsible for
directing and executing the day-to-day
operational objectives of officials and
managers to subordinate personnel and, in
some instances, directly supervising the
activities of exempt and non-exempt
personnel. Examples of these kinds of
managers are: first-line managers; team
managers; unit managers; operations and
production managers; branch managers;
administrative services managers;
purchasing and transportation managers;
storage and distribution managers; call
center or customer service managers;
technical support managers; and brand or
product managers.)
□ Professionals - Occupations requiring
either college graduation or experience of
such kind and amount as to provide a
comparable background. (i.e.: Accounts
and auditors, analysts, architects, designers,
editors, engineers, lawyers, librarians,
photographers, personnel or training
specialists, sales engineers, teachers,
technical writers)
□ Technicians – Occupations requiring a
combination of basic scientific knowledge
and manual skill which can be obtained
through 2 years of post high school
education, such as is offered in many
technical institutes and junior colleges, or
through on-the-job training. (i.e.: Drafters,
technicians, and tool programmers)
□ Sales Workers – Occupations engaged
wholly or primarily in direct selling. (i.e.:
Advertising, cashiers, demonstrators, retail
sales workers, non-retail sales workers,
promoters, supervisors and proprietors of
sales occupations, and travel agents)
□ Office and Clerical – Administrative
support occupations, including all clerical-
type work regardless of level of difficulty,
where the activities are predominately non-
manual through some manual work not
directly involved with altering or
transporting the products is included. (i.e.:
Administrative support occupations
(department, human resources, library,
teaching, etc..) clerks (billing, court, file,
general office, hotel front desk, personnel,
traffic, shipping and receiving, etc…),
computer operators, couriers, dispatchers,
operators, paralegals, receptionists,
secretaries)
□ Craft Workers (Skilled) – Manual workers
of relatively high level (precision production
and repair) having a thorough and
comprehensive knowledge of the process
involved in their work. Exercise
considerable independent judgment and
usually received and extensive period of
training. (i.e.: Automotive mechanics,
construction trades, lay-out workers,
equipment operators, repairers, hourly
supervisors of craft workers trades, office
machine repairers, typesetters)
Note: Exclude learners and helpers of craft
workers.
□ Operative (Semi-skilled) – Workers who
operate transportation or materials moving
equipment, or who operate machine or
processing equipment, or who perform other
factory-type duties of intermediate skill level
which can be mastered in a few weeks and
require only limited training. (i.e.:
Assemblers (electrical, machine, mechanical,
etc..), computer control programmers and
operators, first line supervisors of production
and operating workers, inspectors, operating
engineers, operators (photographic process
machine, press machines, printing press,
textile cutting machine, etc..), solderers,
tool press operators, truck drivers)
Note: Includes UapprenticesU in such fields as
auto mechanics, building and printing trades.
□ Laborers (Unskilled) – Handlers,
equipment cleaners, helpers, and other
workers in manual occupations which
generally require no special training and who
perform elementary duties that any be
learned in a few days and require the
application of little or no independent
judgment. (i.e.: equipment cleaners, first-
line supervisors / managers of landscaping,
lawn service, and groundskeeping workers,
grounds / maintenance workers, handlers
(freight, stock, and material), helpers
(construction, installation, maintenance,
repair, etc..), laborers, logging workers,
vehicle washers)
□ Service Workers – Workers in both
protective and no-protective service
occupations. Includes non-protective workers
in professional and personal service,
amusement and recreation, food service,
maintenance, and unarmed sentinel
occupations. Also includes protective workers
in police and detection, fire fighting, and fire
protection, armed guards and security
occupations. (i.e.: Attendants, child care
workers, cooks, funeral service workers,
hairdressers and cosmetologists,
housekeepers, janitors and cleaners,
lifeguards, pest control workers, personal
home care aides, public service positions
(animal control, firemen, policemen, security
guards), recreation and fitness workers,
residential advisors, supervisors of these
trades, tour and travel guides, wait staff)
NEW EMPLOYEE DATA FORM
Directions:
On the date of hire, the new employee completes the fields in the employee data area.
On-site HR Rep completes the employee race / ethnicity area by visual observation if the employee has not self-identified.
Employee Data:
Employee Name: First
□ Mr. □ Mrs.
□ Ms. □ Dr.
Middle Last Social Security Number:
Home Address: Street City State Zip Code
Date of Birth:
Home Phone Number:
Cell Phone Number:
Personal Email:
Emergency Contact Data:
Emergency Contact:
Relationship to Employee:
Emergency Contact Address: Street City State Zip Code
Primary Phone Number:
Secondary Phone Number:
Email:
Do you ever work outside the USA: □ Yes □ No (If yes, contact your Employer Flexible payroll specialist.)
Do you ever travel outside the USA for work-related purposes? □ Yes □
No (If yes, contact your Employer
Flexible payroll specialist.)
Authorization to Work Data:
Are you an alien authorized to work in the United States: □ Yes □ No
If yes, provide the following information below.
Visa Type:
Visa Expiration Date:
Voluntary Self-Identification Data:
The employer may be subject to certain governmental recordkeeping and reporting requirements for the administration of
civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntary self-
identify their race or ethnicity, veteran or handicapped status, and sex. Submission of this information is voluntary and
refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and
may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those
that require the information to be summarized and reported to the federal government for civil rights enforcement. When
reported, data will not identify any specific individual. We are a company that values diversity.
Race or Ethnicity:
□ Hispanic or Latino
If not Hispanic or Latino, select the race or ethnicity which you identify with below.
□ Black or African American (Not Hispanic or Latino) □ White (Not Hispanic or Latino)
□ American Indian or Alaskan Native (Not Hispanic or Latino) □ Asian (Not Hispanic or Latino)
□
Native Hawaiian or other Pacific Islander (Not Hispanic or Latino)
□
Two or more races (Not Hispanic or Latino)
□
Individual with Disabilities
Gender:
□ Male
□
Female
Veteran Status:
□ Vietnam Era Veteran □ Special Disabled Veteran
□
Other Eligible Veteran
□ I do not wish to Self-Identify Signature:
Date Completed: Signature:
U
Employer Flexible HR, LLC © Copyright 201, All rights reserved
EMPLOYMENT AGREEMENT
Employer Flexible HR, LLC is a PEO (professional employer organization) with Worksite Employer clients and employees
all over the United States. You are an employee of both Employer Flexible HR, LLC and your Worksite Employer, our
customer. Employer Flexible HR, LLC furnishes the administration of payroll, benefits and human resources paperwork,
while your Worksite Employer will supervise your daily work to further its business objectives.
Your employment with Employer Flexible is on an at-will basis, and is for no stated or definite period. This means that
either you or Employer Flexible are free to end the employment relationship for any reason or no reason, and with or
without advance notice. Your employment with the Worksite Employer is also on an at-will basis.
If you have a written employment contract with your Worksite Employer that contract will continue to apply to your
employment relationship with the Worksite Employer. If your written contract with the Worksite Employer provides for
your employment on some basis other than at-will, then this at-will provision will not modify your contract with the
Worksite Employer. Your employment with Employer Flexible will continue on an at-will basis.
If you are aware of any possible harassment or discrimination (whether directed at you or someone else) you are
required to immediately report it to Employer Flexible. You must immediately contact Employer Flexible if your
paycheck does not correctly include all pay or compensation that you believe you are owed. No one is authorized to
make you work off the clock. For example, this means that hourly or non-exempt employees cannot be required to
work unreported overtime. If you submit a timesheet, you are responsible for ensuring that each timesheet is
complete and accurate, and correctly shows all hours you actually worked. While you are required to obtain pre-
approval to work overtime hours, any overtime hours actually worked (whether pre-approved or not) must still be
reported.
To the extent required by state law, Employer Flexible has agreed to pay your wages, to the extent your wages are
timely and accurately reported to us by our Client. Employer Flexible does not offer any bonus plans, commission
plans, paid leave plans, profit sharing plans or deferred compensation plans. Your Worksite Employer (our customer)
may offer such plans. To the extent that the Worksite Employer offers any such plans, payment under those plans is
the sole obligation of our customer. Employer Flexible’s only responsibility is to process payment to Employees as
directed by the Worksite Employer and to the extent of the funds actually received from the Worksite Employer.
Dispute Resolution. Employer Flexible has adopted a dispute resolution plan, the Solutions Plan. All disputes between
You and Employer Flexible shall be resolved exclusively through final and binding arbitration under the Federal
Arbitration Act, and administered by the American Arbitration Association under its Employment Arbitration Rules and
the Employer Flexible Solutions Plan. If the Worksite Employer that has adopted the Solutions Plan, then disputes
between You and the Worksite Employer shall also be subject to final and binding arbitration under the Employer
Flexible Solutions Plan as provided by the Plan. The decision of the arbitrator shall be final and binding on You and on
Employer Flexible (and the Worksite Employer, if applicable), and may be enforced in any court with jurisdiction. This
agreement to arbitrate all disputes shall survive the expiration, termination or breach of this Employment Agreement,
and applies to claims first asserted after termination of employment, even if that termination is alleged to be
wrongful. In addition, both Employee and Company waive all right to a trial by jury in any action between them, in any
forum.
Accurate Information. I represent that all information I provided on any forms or other documents filled out in
connection with my employment, and all information provided in any interview, is complete, true and correct. I have
withheld nothing that would, if disclosed, affect my employment relationship unfavorably or might lead a reasonable
employer to make further inquiry or to decide against hiring. I understand that if I am employed and any such
information is later found to be false or incomplete in any respect, I may be dismissed.
I understand it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in
the United States, and that federal immigration laws require me to complete the Form I-9.
Initial_____________ Date_____________
Page 1 of 3
Employer Flexible HR, LLC © Copyright 201, All rights reserved
UEMPLOYMENT AGREEMENT
Important Notice about Unemployment Benefits. You are required to report back to Employer Flexible if you are laid
off or terminated from your position and desire Employer Flexible to attempt to reassign you to a different one of our
clients. Reassignment is not guaranteed. Important - under Texas law if you fail to report back to Employer Flexible
and request reassignment you may be denied state unemployment insurance benefits. If you wish to be considered for
reassignment and to maintain eligibility for unemployment insurance benefits you must contact Employer Flexible in
person or in writing not later than two business days after the day your employment terminates. If you do not contact
Employer Flexible in person or in writing, you may lose your right to receive unemployment insurance benefits from
the State of Texas.
Drug Testing. Co-operation with drug and alcohol testing is a condition of employment and/or continued
employment. Drug and alcohol testing may be required as part of pre-employment screening, randomly, based on
reasonable suspicion or after an on-the-job accident or injury. Failure to submit to screening or failure to reasonably
cooperate with screening tests will result in termination of employment. Positive test results may result in discipline,
up to and including termination of employment.
Changes. No implied, oral, or written agreement contrary to the express language of this Agreement are valid unless
they are in writing and signed by the Chief Executive Officer of Employer Flexible or the Chief Executive Officer of the
Worksite Employer, as appropriate. No supervisor or representative of the Employer Flexible, other than the Chief
Executive Officer, has any authority to make any agreements contrary to this agreement for at-will employment. This
agreement takes the place of all prior and contemporaneous agreements, representations, and understandings
between employee and Employer Flexible.
If you have any questions regarding this statement, please call Employer Flexible 1-888-983-5879 before signing. By
signing, you acknowledge that you have read and understood this agreement.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT AND AGREEMENT
_____________________________________________________________________________
SIGNATURE OF EMPLOYEE DATE SS#
Page 2 of 3
Employer Flexible HR, LLC © Copyright 201, All rights reserved
UEMPLOYMENT AGREEMENT
Background Check Disclosure & Consent
In connection with my application for employment, I understand and agree that Employer Flexible or my
Worksite Employer may obtain a consumer report and/or investigative consumer report concerning me. An
investigative consumer report is a special type of consumer report that is obtained through interviews and may
contain information about my character, general reputation, personal characteristics, and/or mode of
living. Upon my written request within a reasonable period of time, a complete disclosure of the nature and
scope of that investigation will be made to me in writing within five days of the date on which the request was
received. During my employment, I authorize Employer Flexible or my Worksite Employer to obtain a consumer
report and/or investigative consumer report about me for employment related purposes, to the full extent
allowed by law. By signing below, I am authorizing Employer Flexible or my Worksite Employer to obtain
consumer reports or investigative consumer reports.
I authorize all corporations, employers, co-workers, references, credit reporting agencies, educational
institutions, licensing bodies, courts, law enforcement agencies, governmental agencies or departments, and
military services to provide information about my background, including but not limited to driving records, court
records, criminal records, credit report, academic records, professional license record and employment
information or records. I agree to release the aforesaid from any liability for providing that information.
I agree that Employer Flexible and my Worksite employer may share with each other and disclose to each other
the results of any background check, consumer report or investigative consumer report.
I agree that this Disclosure will be valid, now or in the future, in original, faxed, copied or electronic form.
If you have any questions regarding this statement, please call Employer Flexible 1-888-983-5879 before signing.
By signing, you acknowledge that you have read and understood this agreement.
DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT AND AGREEMENT
_____________________________________________________________________________
SIGNATURE OF EMPLOYEE DATE SS#
Page 3 of 3
Employer Flexible HR, LLC © Copyright 201, All rights reserved
DIRECT DEPOSIT FORM
Employee Information
Employee Name:
Last 4 digits of Soc. Sec. No:
Client Company Name:
Work Phone:
Email: (For online paystub notification) □ Home □ Work
□ New Enrollment □ Decline
□ Add / Change □ Delete
Home Phone:
Employee Signature:
Date:
I hereby authorize Employer Flexible HR, herein referred to as Employer / Company, to initiate credit entries (deposits) and to initiate, if necessary,
debit entries (withdrawals) and adjustments for any credit entries made in error to my account(s) indicated below, to credit and / or debit the same
to such account(s). It is my responsibility to provide accurate data and to notify Employer Flexible of any changes or corrections to my financial
institution account information. I acknowledge that if I submit a change in financial institution information, that I may receive one or more physical,
negotiable paycheck(s) until the new Bank information is processed. I understand that any new or changed direct deposit(s) will not be processed for
approximately 3 weeks from Employer Flexible HR’s receipt of this form. It is understood that the following situations may result in my receiving a
physical, negotiable paycheck: network electronic failure, my becoming subject to any attachment, garnishment, or levy, or if I terminate
employment. I agree to hold harmless the above named Bank(s) and Employer Flexible for any erroneous deposits or adjustments. I understand that
Employer Flexible reserves the right to reverse direct deposit of funds paid in error. I understand that it is my responsibility to verify funds deposited
into my designated account(s) prior to performing transactions on expected funds. Neither Employer Flexible nor
__________________________________________ (Client Company) is responsible for insufficient funds charges posted to my designated account(s) due
to errors in electronic funds transfer.
Because you have elected direct deposit, you will receive electronic paystubs. On your payday, you will be sent an email to the address you indicated
above which contains a reminder along with a secured link to access, view, and or print your records. I understand that I can obtain a written copy of
my paystub information at any time by making a request to Employer Flexible.
Primary Banking Information
Bank Name:
Bank Phone:
Bank Address:
□ Checking Amt: $_______ (if NET, write NET)
Routing Code: __ __ __ __ __ __ __ __ __
Account No:
□ Savings Amt: $_______ (if NET, write NET)
Routing Code: __ __ __ __ __ __ __ __ __
Savings Acct. No:
Secondary Banking Information
Bank Name:
Bank Phone:
Bank Address:
□ Checking Amt: $_______ (if NET, write NET)
Routing Code: __ __ __ __ __ __ __ __ __
Account No:
□ Savings Amt: $_______ (if NET, write NET)
Routing Code: __ __ __ __ __ __ __ __ __
Savings Acct. No:
ATTACH YOUR PERSONAL CHECK(S)
MARKED “VOID” HERE
Employer Flexible HR, LLC © Copyright 201, All rights reserved
Acknowledgement of Orientation Handbook
By signing below, I acknowledge that I have read, and understand, the policies contained within the Orientation
Handbook, and I will comply with the requirements of the policies.
UI understand that this Orientation Handbook represents Uonly current policies and benefits, and that it
does not create a contract of employment. U
Your company and Employer Flexible HR, LLC retain the right to change these policies and benefits, as it deems
advisable.
Unless expressly proscribed by statute or contract, my employment is
"
at-will.
"
I understand that I have the right to
terminate my employment at any time, with or without cause or notice, and that the Company has the same right. I
further understand that my status as an "at-will" employee may not be changed except in writing and signed by the
President of Employer Flexible HR, LLC.
I understand that the information I come into contact with during my employment is proprietary to the Company and
accordingly, I agree to keep it confidential, which means I will not use it other than in the performance of my duties,
or disclose it to any person or entity outside the Company. I understand that I must comply with all of the provisions
of the Handbook to have access to and use Company resources. I also understand that if I do not comply with all
provisions of the Handbook, my access to Company resources may be revoked, and I may be subject to disciplinary
action up to and including discharge.
I further understand that I am obligated to familiarize myself with the Company
'
s safety, health, and emergency
procedures as outlined in this Handbook or in other documents.
Please Print Your Name
Please Sign Your Name
Date
Client Company Name
Employee Acknowledgment of Workers’ Compensation Network
I have received information that informs me how to get health care under my employer’s workers’
compensation insurance.
,I,DPKXUWRQWKHMREDQGOLYHLQDVHUYLFHDUHDGHVFULEHGLQWKLVSDFNHW,XQGHUVWDQGWKDW
Knowingly making a false workers’ compensation claim may lead to a criminal investigation that could
UHVXOWLQFULPLQDOSHQDOWLHVVXFKDV¿QHVDQGLPSULVRQPHQW
_____________________________ ____________ ___________________________
Signature Date Printed name
,OLYHDWBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Street address
___________________________________________________________
&LW\ 6WDWH=LSFRGH
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1DPHRIQHWZRUN:RUN:HOO7;
• I must choose a treating doctor from the list of doctors in the network. Or, I may ask my
HMO primary care physician to agree to serve as my treating doctor. If I select my HMO
SULPDU\FDUHSK\VLFLDQDVP\WUHDWLQJGRFWRU,ZLOOFDOO7H[DV0XWXDO,QVXUDQFH&RPSDQ\DW
WRQRWLI\WKHPRIP\FKRLFH
• I must go to my treating doctor for all health care for my injury. If I need a specialist, my
treating doctor will refer me to a specialist. If I need emergency care, I may go anywhere.
• Texas Mutual will pay the treating doctor and other network providers for the treatment for
my compensable injury.
• I may have to pay the bill if I get health care from someone other than a network doctor
without prior network approval.
To the employer:
Each employee must sign this form when you begin the program or within 3 days of being hired,
and at the time an injury occurs. Please indicate at which point this acknowledgement
was completed.
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LB-1234-1708 • ©2017 Texas Mutual Insurance Company
Employer Flexible HR, LLC © Copyright 201, All rights reserved
Wage Deduction Authorization Agreement
I understand and agree that my employer, Employer Flexible, may deduct money from my pay from time to time
for reasons that fall into the following categories:
1. my share of the premium contributions to any Company benefit programs;
2. any contributions I may make into a retirement or pension plan sponsored, controlled, or managed by the
Company;
3. installment payments on loans or wage advances given to me by the Company, and if there is a balance
remaining when I leave the Company, the balance of such loans or advances;
4. if I receive an overpayment of wages for any reason, repayment to the Company of such overpayments (the
deduction for such a repayment will equal the entire amount of the overpayment, unless the Company and I
agree in writing to a series of smaller deductions in specified amounts);
5. the cost of repairing or replacing any Company supplies, materials, equipment, money, or other property
that I may damage (other than normal wear and tear), lose, fail to return, or take without appropriate
authorization from the Company during my employment (except in the case of misappropriation of money by
me, I understand that no such deduction will take my pay below minimum wage, or, if I am a salaried
exempt employee, reduce my salary below its predetermined amount);
6. if I take paid vacation or sick leave in advance of the date I would normally be entitled to it and I separate
from the Company before accruing time to cover such advance leave, the value o f such leave taken in
advance that is not so covered;
7. the value of any time off for absences to which paid leave is not applied (non -exempt salaried employees
will have all such unpaid leave deducted from their salary, while exempt salaried employees wil l experience
salary reductions only in units of a full day or week at a time, depending upon the exact nature of the
absence, unless partial-day deductions are specifically allowed under federal law); and,
8. if my employer pays any insurance premiums or retirement system contributions ("payments") on my behalf
that I would normally make under the applicable Company benefit plan, the amount of such payments made
by the Company, such payments being an advance of future wages payable to me.
I agree that the Company may deduct money from my pay under the above circumstances, or if any of the above
situations occur. I further understand that the Company has stated its intention to abide by all applicable federal
and state wage and hour laws and that if I believe that any such law has not been followed, I have the right to file a
wage claim with appropriate applicable state and federal agencies.
__________________________________ __________________
Signature of Employee Date
__________________________________
Employee's Name - Printed
__________________________________ __________________
Company Representative Date
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
▶
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
▶
Give Form W-4 to your employer.
▶
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
▶
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
▶
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
▶
$
Multiply the number of other dependents
by $500 . . . .
▶
$
Add the amounts above and enter the total here . . . . . . . . . . . . .
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b)
Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here . . . . . . . . . . . . . . . . . . . . .
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
▲
Employee’s signature (This form is not valid unless you sign it.)
▲
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2020)
Form W-4 (2020)
Page 2
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you will
generally be due a refund. Complete a new Form W-4 when
changes to your personal or financial situation would change
the entries on the form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
Exemption from withholding. You may claim exemption from
withholding for 2020 if you meet both of the following
conditions: you had no federal income tax liability in 2019 and
you expect to have no federal income tax liability in 2020. You
had no federal income tax liability in 2019 if (1) your total tax on
line 16 on your 2019 Form 1040 or 1040-SR is zero (or less
than the sum of lines 18a, 18b, and 18c), or (2) you were not
required to file a return because your income was below the
filing threshold for your correct filing status. If you claim
exemption, you will have no income tax withheld from your
paycheck and may owe taxes and penalties when you file your
2020 tax return. To claim exemption from withholding, certify
that you meet both of the conditions above by writing “Exempt”
on Form W-4 in the space below Step 4(c). Then, complete
Steps 1(a), 1(b), and 5. Do not complete any other steps. You
will need to submit a new Form W-4 by February 16, 2021.
Your privacy. If you prefer to limit information provided in
Steps 2 through 4, use the online estimator, which will also
increase accuracy.
As an alternative to the estimator: if you have concerns
with Step 2(c), you may choose Step 2(b); if you have
concerns with Step 4(a), you may enter an additional amount
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box
in Step 2(c), which will increase your withholding and
significantly reduce your paycheck (often by thousands of
dollars over the year).
When to use the estimator. Consider using the estimator at
www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to
additional taxes, such as the additional Medicare tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job
situations.
Self-employment. Generally, you will owe both income and
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an
employee. If you want to pay these taxes through
withholding from your wages, use the estimator at
www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice
1392, Supplemental Form W-4 Instructions for Nonresident
Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
compute your withholding.
Step 2. Use this step if you (1) have more than one job at the
same time, or (2) are married filing jointly and you and your
spouse both work.
Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
little less accuracy.
If you (and your spouse) have a total of only two jobs, you
may instead check the box in option (c). The box must also be
checked on the Form W-4 for the other job. If the box is
checked, the standard deduction and tax brackets will be cut
in half for each job to calculate withholding. This option is
roughly accurate for jobs with similar pay; otherwise, more tax
than necessary may be withheld, and this extra amount will be
larger the greater the difference in pay is between the two jobs.
▲
!
CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. Step 3 of Form W-4 provides instructions for
determining the amount of the child tax credit and the credit
for other dependents that you may be able to claim when
you file your tax return. To qualify for the child tax credit, the
child must be under age 17 as of December 31, must be
your dependent who generally lives with you for more than
half the year, and must have the required social security
number. You may be able to claim a credit for other
dependents for whom a child tax credit can’t be claimed,
such as an older child or a qualifying relative. For additional
eligibility requirements for these credits, see Pub. 972, Child
Tax Credit and Credit for Other Dependents. You can also
include other tax credits in this step, such as education tax
credits and the foreign tax credit. To do so, add an estimate
of the amount for the year to your credits for dependents
and enter the total amount in Step 3. Including these credits
will increase your paycheck and reduce the amount of any
refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other
estimated income for the year, if any. You shouldn’t include
income from any jobs or self-employment. If you complete
Step 4(a), you likely won’t have to make estimated tax
payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5, if you expect to claim deductions other than
the basic standard deduction on your 2020 tax return and
want to reduce your withholding to account for these
deductions. This includes both itemized deductions and other
deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want
withheld from your pay each pay period, including any
amounts from the Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund or reduce any amount of tax that you owe.
Form W-4 (2020)
Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $
2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a
$
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2b $
c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c
$
3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and local
taxes (up to $10,000), and medical expenses in excess of 7.5% of your income . . . . . . . 1 $
2 Enter:
{
• $24,800 if you’re married filing jointly or qualifying widow(er)
• $18,650 if you’re head of household
• $12,400 if you’re single or married filing separately
}
. . . . . . . . 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . 3 $
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information 4 $
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $
Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. Internal
Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to
provide this information; your employer uses it to determine your federal income
tax withholding. Failure to provide a properly completed form will result in your
being treated as a single person with no other entries on the form; providing
fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws; and to the Department of
Health and Human Services for use in the National Directory of New Hires. We
may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
Form W-4 (2020)
Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870
$10,000 - 19,999
220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070
$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900
$30,000 - 39,999
900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100
$40,000 - 49,999
1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220
$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220
$60,000 - 69,999
1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220
$70,000 - 79,999
1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240
$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180
$150,000 - 239,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250
$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170
$260,000 - 279,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770
$280,000 - 299,999
2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370
$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970
$320,000 - 364,999
2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840
$365,000 - 524,999
2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280
$525,000 and over
3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040
$10,000 - 19,999
940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830
$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110
$30,000 - 39,999
1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310
$40,000 - 59,999
1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080
$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060
$80,000 - 99,999
2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060
$100,000 - 124,999
2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620
$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370
$150,000 - 174,999
2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120
$175,000 - 199,999
2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230
$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$250,000 - 399,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$400,000 - 449,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540
$450,000 and over
3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040
$10,000 - 19,999
830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440
$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850
$30,000 - 39,999
1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140
$40,000 - 59,999
1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380
$80,000 - 99,999
1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380
$100,000 - 124,999
2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870
$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620
$150,000 - 174,999
2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370
$175,000 - 199,999
2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980
$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$250,000 - 349,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$350,000 - 449,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200
$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
