Fillable 2019 Form W-4 - Fw4.pdf (Fulton County Government)

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2019 Form W-4 - Fw4.pdf (Fulton County Government)

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•
Revised Ju
ly 2015
TAKE ADVANTAGE OF DIRECT DEPOSIT AND PAY CARDS TODAY
Your paycheck will be credited to your account on pay day through either Direct Deposit to your own
Banking Institution OR Fulton County’s PayCard Program through Bank of America. Select one of the
options below and return completed form(s) to the Payroll and Benefits Division for processing.
Completed forms may be faxed to (404) 730-7610 for processing!
PAYROLL DEADLINE
The payroll deadline is 12 noon on the Friday before pay day.
1. Direct Deposit – Forms received by the payroll deadline will take effect on the next pay day.
2. Pay Cards – Forms received by the payroll deadline will take effect two (2) pay days later.
LEGAL NAME:
EMPLOYEE ID# OR LAST 4 OF SSN:
DEPARTMENT:
PHONE NO.
SELECT ONE OF THE FOLLOWING OPTIONS:
You must attach a copy of a voided check for a checking account deposit. If you choose a savings
account deposit, documentation from your bank is required as to the correct routing number and
account number to process your direct deposit.
NAME OF BANK:
ROUTING NO. (First grouping of 9 numbers at the bottom of your check)
PLEASE CHECK ONE BELOW:
DEPOSIT TO MY CHECKING ACCOUNT
Voided Check Attached
ACCT. NO.
DEPOSIT TO MY SAVINGS ACCOUNT
Bank Documentation
Attached
ACCT. NO.
I understand that I can terminate the direct deposit of payroll by giving written notice, subject to Finance Department Payroll
deadlines and be automatically enrolled in the Pay Card Program. I authorize credit entries and any adjustments to be made to
my account. I understand that if my account is closed or changes are made after the payroll deadline, it will result in a delay of my
direct deposit payroll funds. I also understand that if my payroll funds are returned to Fulton County I will be automatically
enrolled in the Pay Card program if updated banking information is not received by the next payroll deadline. If I am automatically
enrolled in the Pay Card Program, I have been provided with a list of the applicable fees associated with this account.
DEPARTMENT OF FINANCE
PAYROLL & EMPLOYEE BENEFITS DIVISION
141 PRYOR STREET, S.W., SUITE 7001
ATLANTA, GEORGIA 30303
TELEPHONE (404) 612 -7605 or (404) 612-7724
FAX: (404) 730-7610
In lieu of the Direct Deposit Program to my Banking Institution of choice, the Fulton County
PayCard should be set up. I have been provided with a list of any applicable fees associated
with this account. I authorize credit entries and any payroll adjustments to be made to my
account.
Signature of Employee: _______________________________ Date: _____________________________
I understand that if I do not select an option from above, I will be automatically enrolled in the Fulton County
Payroll Card Program through Bank of America.
Pursuant to the Georgia Security and Immigration Compliance Act of 2006 (Senate Bill 529.GSICA), every
agency administering or providing public benefits is responsible for determining U.S. citizenship or lawful alien
status of applicants for said benefits. (O.C.G.A. § 50-36-1)
By executing this affidavit under oath, as an applicant for a retirement, disability, and/or health insurance
benefits, the undersigned applicant verifies one of the following with respect to his/her application for a public
benefit from Fulton County Government.
1. _____ I am a United States citizen.
2. _____ I am a legal permanent resident of the United States.
3. _____ I am a qualified alien or non-immigrant under the Federal Immigration and Nationality Act with an
alien number issued by the Department of Homeland Security or other federal immigration
agency.
My alien number issued by the Department of Homeland Security or other federal immigration
agency is: ___________________________________________________.
The undersigned applicant also hereby verifies that he or she is 18 years of age or older and has provided at
least one secure verifiable document listed below, as required by O.C.G.A..§ 50-36-1(e)(1), with this affidavit.
The following list of secure and verifiable documents, published under the authority of O.C.G.A.§ 50-36-2,
contains documents that are verifiable for identification purposes, and documents on this list may not
necessarily be indicative of residency or immigration status.
•An Unexpired United States Passport or Passport Card
• An Unexpired United States Military Identification Card
• An Unexpired Driver’s License issued by the United States
• An Unexpired identification card issued by the United States
• An Unexpired Tribal Identification Card of a federally recognized Native American Tribe
• An Unexpired US Permanent Resident Card or Alien Registration Receipt Card
• An Unexpired Employment Authorization Document that contains a photograph of the bearer
• An Unexpired Merchant Mariner Document or Credential issued by U.S. Coast Guard
• An Unexpired Free and Secure Trade (FAST) Card
• An Unexpired Certificate of Citizenship issued by the United States Department of Citizenship
• An Unexpired Certificate of Naturalization issued by the United States Department of Citizenship
• An Unexpired Passport issued by a Foreign Government provided that such passport is accompanied by a United States
Department of Homeland Security (“DHS”) Form I-94, DHS Form I-94A, DHS Form I-94W, or other federal form specifying an
individual’s lawful immigration status or other proof of lawful presence under federal immigration law.
The secure and verifiable document provided with this affidavit can best be classified as:
(list document and provide a copy) _______________________________________________
In making the above representation under oath, I understand that any person who knowingly and
willfully makes a false, fictitious, or fraudulent statement or representation in an affidavit shall be guilty
of a violation of O.C.G.A. § 16-10-20 and face criminal penalties as allowed by such criminal statute.
Executed in _________________________ (city), ______________________ (state)
_________________________________________
Signature of Applicant
_________________________________________
Printed Name of Applicant
Subscribed and sworn before me on this the
___________ day of __________________________, 20______
Notary public: _________________________________________
My commission expires: _________________________________
Fulton County Government
Affidavit Verifying Eligibility Status for Public Benefit(s)
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2019 Form W-4 - Fw4.pdf (Fulton County Government)

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Completed 17 July 2020

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