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Adjunct (Cisco College)

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CiscoCollege–January2015

Adjunct

Faculty

NewHire

Packet

(AcademicYear2019‐20)

New Employee Information

Title:

Last Name:

First Name:

Social Security #

Address:

City,State,Zip:

Home Phone:

Cell Phone:

____________________________________________

Cisco College IT Acceptable Use Policy:

Yes, I have read the Cisco College IT Acceptable

Use Policy.

Policy is available at: http://www.cisco.edu/

s/926/images/editor_documents/hr_forms/

ciscocollegepolicymanual-spring2016.pdf

Full Time Part Time

Primary Location

Cisco Abilene

FT/PT

PayCheck Disbursement:

I will pick up my check in Abilene

I will pick up my check in Cisco

I have Direct Deposit:

(please specify mail or pick up for first check)

Mail my paycheck to the following address:

__________________________________

_________________________________________________________________________________

____________________________________________________________________________________________________________

_________________________________________________________________________________

____________________________________________________________________________________________________________

(Click link above to view Policy)

Emergency Contact Person:

Relationship to Emergency Contact:

Emergency Contact Address:

Emergency Contact City, State, Zip:

________________________________________

__________________________________

_______________________________________

__________________________________

Emergency Contact Home phone: ____________________________________

Emergency Contact Work Phone: ____________________________________

Emergency Contact Cell Phone: _____________________________________

Highest Degree Earned:

Ethnicity:

Employee Classification:

Home Phone Available to Students: Yes

Home Email Available to Students:

Yes

Employee Signature: _________________________________Date: ____________________

_________________________________________________________________________________

____________________________________________________________________________________________________________

_________________________________________________________________________________

Job Title:______________________________________________________

Faculty Position:

Division:

Hire Date: _____________________________

Home Email: ___________________________________________________

____________________

__________________________

______________________________

_____________________________

______________________________

BIOGRAPHIC REPORT

NAME:______________________________________________________________________

ADDRESS:__________________________________________________________________

Street City State Zip

Telephone Number:____________________________________________________________

Social Security Number:________________________________________________________

Highest Degree or Certificate:____________________________________________________

Institution of Highest Degree:____________________________________________________

Area of Specialization:__________________________________________________________

Date of Birth:_________________________________________________________________

Total Teaching Experience:______________________________________________________

Date of Employment:___________________________________________________________

Job Title:____________________________________________________________________

Teaching Experience at Cisco College:_____________________________________________

Teaching Experience other than Cisco College:______________________________________

Ethnic origin – Please check only one:

American-Indian/Alaskan Native _______

Asian _______

Black _______

Hispanic _______

White _______

Other _______ Date:__________________

PART-TIME EMPLOYEE

RETIREMENT INFORMATION (TRS)

*** Thi

s form MUST BE Completed!! ***

SOCIAL SECURITY NUMBER_________________________________________

LAST NAME________________________________________________________

FIRST NAME___________________________MIDDLE INITIAL_______________

1. Have you ever worked for a TRS-covered employer*?

YES__________NO___________

*State supported universities, medical and dental schools, junior/community colleges, public

schools, regional education service centers, certain charter schools

If NO

, please fill out the “Part-Time Employee Retirement Selection Form” to choose

between MetLife (FICA Alternative Plan) and enrollment form OR Social Security.

2. Did you contribute to TRS during this period of employment?

YES_________ NO__________

3. If the answer to #2 is yes, have you withdrawn your funds from TRS?

YES_________ NO__________

4. If the answer to #2 is NO, do you receive a monthly retirement check from TRS? (If

the answer is YES (I do receive a retirement check).

YES_________ NO__________

If YES, Retirement Date _____________________

5. Are you currently employed by another TRS-covered employer?

YES_____ NO_____ If YES, is it full or part time? FULL______ PART _______

Employer’s Name? __________________________________________________

PART-TIME EMPLOYEE

RETIREMENT SELECTION FORM

*** (This form MUST be completed!!)***

1. _________ MetLife

In consideration of my employer’s obligations under the Cisco College Tax Sheltered Annuity

Plan (the “Plan”), I hereby elect to defer 6.2% of total Compensation (as defined in the Plan) for

services rendered after the date of this Salary Reduction Agreement. I hereby authorize my

employer to effect such deferrals by payroll deduction each pay period. In making this election, I

understand that my deferrals are being made on a before tax basis which means I am agreeing to

have my Compensation reduced by the states percentages and, in turn my employer will

contribute my Compensation reduction amounts to the Plan on my behalf, and such amounts will

be applied toward the premiums payable on the annuity contract obtained for me pursuant to the

Plan. I also understand that my employer has a right to reduce my elected percentage as may be

legally required in order to comply with section 403(b) and any and all other sections of the

Internal Revenue Code. I further understand that I may not change my elected percentage nor

revoke this Salary Reduction Agreement at any time prior to termination of my employment with

my employer.

2. _______ Social Security

3. _______ Teachers Retirement System of Texas

(Only available to part-time employees who are concurrently employed

full-time with TRS-eligible employer – As indicated on completion of

TRS Retirement Form.)

____________________________________

Signature of Participant Date

____________________________________

Participant’s Name – Please Print

CISCO COLLEGE

____________________________________

Agreed to by Employer Date

Cisco College

Annuity/Non-Erisa

1008792

Fax: 732-893-6414

6.2

Employer Information

1. Federal Employer ID Number (FEIN): 2. State Employer ID Number (Optional):

Please use the same FEIN that appears on quarterly wage reports.

3. Employer Name:

4. Employer Address (Please indicate the address where the Income Withholding Orders should be sent):

5. Employer City (if US): 6. State (if US): 7. ZIP Code (if US):

8. Province/Region (if foreign): 9. Country (if foreign): 10. Postal Code (if foreign):

11. Employer Telephone (Optional): 12. Employer FAX (Optional):

13. New Hire Contact Person (Optional):

Employee Information

14. Social Security Number (SSN): 15. Date of Hire (MM/DD/YYYY):

16. Employee First Name:

17. Employee Middle Name:

18. Employee Last Name:

19. Employee Home Address:

20. Employee City (if US): 21. State (if US): 22. ZIP Code (if US):

23. Province/Region (if foreign): 24. Country (if foreign): 25. Postal Code (if foreign):

26. State Where Employee Was Hired (Optional): 27. Employee DOB (MM/DD/YYYY) (Optional):

28. Employee’s Salary (Dollars and Cents) (Optional):

29. Salary Frequency (Check One ONLY) (Optional):

Hourly

Weekly

Biweekly

Semi-Monthly

Monthly

Annually

Texas Employer New Hire Reporting Form

Submit within 20 calendar days of new employee’s

first day of work to:

ENHR Operations Center, P.O. Box 149224

Austin, TX 78714-9224

Phone: 1-800-850-6442 FAX: 1-800-732-5015

Online: www.employer.texasattorneygeneral.gov

To ensure the highest level of accuracy, please print neatly

in capital letters and avoid contact with the edges of the

boxes. The following will serve as an example:

REV 12/13 ENHR RPT FORM

7 5 1 1 6 4 3 4 3

C I S C O C O L L E G E

6 0 1 C O L L E G E H E I G H T S

C I S C O

T X

7 6 4 3 7

2 5 4 4 4 2 5 1 2 1

2 5 4 4 4 2 5 1 0 0

INSTRUCTIONS FOR COMPLETING THE TEXAS EMPLOYER NEW HIRE REPORTING FORM

The purpose of the Texas New Hire Reporting Form is to allow employers to fulfill new hire reporting requirements. You may enter your

employer information and photocopy a supply and then enter employee information on the copies.

REPORTING OF NEW HIRES IS REQUIRED:

All required items (numbers 1, 3, 4, 5, 6, 7, 14, 15, 16, 17, 18, 19, 20, 21, 22) on this form must be completed.

Box 1: Federal Employer ID Number (FEIN). Provide the 9-digit employer identification number that the federal government assigns to the

employer. This is the same number used for federal tax reporting. Please use the same FEIN that appears on quarterly wage reports.

Box 2: State Employer ID Number (Optional). Identification number assigned to the employer by the Texas Workforce Commission.

Box 3: Employer Name. The employer name as listed on the employee’s W4 form. Please do not provide more than one employer name

(for example, “ABC, Inc DBA. John Doe Paint and Body Shop” is not correct).

Box 4: Employer Address. Please indicate the address where the Income Withholding Orders should be sent. Do not provide more

than one address (for example, P.O. Box 123, 1313 Mockingbird Lane is not correct).

Box 8: Employer Province/Region (if foreign). Provide this information if the employer address is not in the United States.

Box 9: Employer Country (if foreign). Provide the two letter country abbreviation if the employer address is not in the United States.

Box 10: Postal Code (if foreign). Provide the postal code if the employer address is not in the United States.

Box 13: New Hire Contact Person (Optional). Providing the name of a contact staff person will facilitate communication between the

employer and the Texas Employer New Hire Reporting Program.

Box 15: Date of Hire. List the date in month, day and year order. Use four digits for the year (for example, 2001). This should be the first

day that services are performed for wages by an individual. If you are reporting a rehire (where a new W-4 is prepared) use the return date,

not the original date of hire.

Box 23: Employee Province/Region (if foreign). Provide this information if the employee does not reside in the United States.

Box 24: Employee Country (if foreign). Provide the two letter country abbreviation if the employee address is not in the United States.

Box 25: Postal Code (if foreign). Provide the postal code if the employee address is not in the United States.

Box 26: State Where Employee was Hired. Use the abbreviation recognized by the U.S. Postal Service for the state in which the

employee was hired.

Box 27: Employee DOB (Date of Birth) (Optional). List the date in month, day and year order. Use four digits for the year (for example,

1985).

Box 28: Employee Salary (Optional). Enter employee’s exact wages in dollars and cents. This should correspond to the salary pay

frequency indicated in Box 29.

Box 29: Salary (Check One ONLY) (Optional). Check the appropriate box relating to the employee’s salary pay frequency. Check “ Bi-

weekly” if the salary is based on 26 pay periods. Check “Semi-monthly” if the salary is based on 24 pay periods. Check “Annually” if salary

payment is a one-time distribution.

SUBMISSION OF NEW HIRE REPORTS. The Texas Employer New Hire Reporting Program offers a variety of methods that employers

can use to submit new hire reports. For further information on which method may be best for you, call 1-800-850-6442. Employers are

encouraged to keep photocopies or electronic records of all reports submitted. When the form is completed, send it to the Texas Employer

New Hire Reporting Program using one of the following means:

 FAX: 1-800-732-5015

 U.S. Mail:

ENHR Operations Center

P.O. Box 149224

Austin, TX 78714-9224

 Telephone Submissions: 1-800-850-6442

 Internet Submissions: www.employer.texasattorneygeneral.gov

Employers must provide all of the required information within 20 calendar days of the employee's first day of work to be in

compliance. State law provides a penalty of $25 for each employee an employer knowingly fails to report, and a penalty of $500 for

conspiring with an employee to 1) fail to file a report or 2) submit a false or incomplete report.

REV 12/13 ENHR RPT FORM

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) $

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)

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.

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.

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

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

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.)

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 08/31/2019

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N

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)

U.S. Social Security Number

Employee's E-mail Address

Employee's Telephone Number

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):

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.

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:

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 07/17/17 N

Page 2 of 3

USCIS

Form I-9

OMB No. 1615-0047

Expires 08/31/2019

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