Fillable Employee Personal Information Form

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Employee Personal Information Form

On average this form takes 12 minutes to complete

The Employee Personal Information Form form is 17 pages long and contains:

  • 3 signatures
  • 19 check-boxes
  • 28 other fields

Country of origin: US
File type: PDF

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ACA_________ HR 11/2016 | HRPIF
Employee Personal Information Form
Employee type: ___Classified ___Student ___Volunteer ___PT Faculty ___FT Faculty ___Exempt _____PT Hourly
Department Name: ___________________________ Supervisor Name: __________________________________
YOUR PERSONAL INFORMATION
Last Name: ____________________________________ First Name:_____________________________________
Preferred Name: ______________________________________________________________________________
Street Address: _______________________________________________________________________________
City: __________________________________________ State: _______________ Zip code: _________________
Primary Phone number: ___________________________ Secondary Phone number: _______________________
Mailing Address (If different): ____________________________________________________________________
City: ________________________________________ State: _______________ Zip Code: ___________________
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: _______________________________________________________________________
Relationship to self: ______________________________ Contact Phone: _________________________________
EMPLOYEE SIGNATURE REQUIRED
Employee Signature: __________________________________________ Date: ____________________________
FOR HUMAN RESOURCES OFFICE USE ONLY
Entered: _______________________________________ Date: ______________________________________
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
a
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
a
Give Form W-4 to your employer.
a
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
a
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 . . . . .
a
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
a
$
Multiply the number of other dependents
by $500 ....
a
$
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.
F
Employee’s signature (This form is not valid unless you sign it.)
F
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 1a, 1b, 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.
F
!
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 10% 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 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.
HR 11/2016 | HRDEMO
Employee Demographic Data Form
Government agencies require periodic reports on the gender, ethnic origin, and veteran status of employees. Persons hired
or already employed by the college are required to provide the information below. This information will be treated as
confidential and will be available only to authorized personnel.
Last Name: ______________________________________
First Name: ______________________________________
Social Security Number: ____________________________
Birthdate: ____________________ __ FEMALE __ MALE
ETHNICITY/HISPANIC ORIGIN
ARE YOU OF HISPANIC ORIGIN? ___yes (717) ___no (999)
Hispanic origin includes all persons having origins in Mexico, Puerto Rico, Cuba, Central or South America, or other countries of Spanish culture, regardless
of race. It does not include persons from Portuguese speaking cultures such as Portugal or Brazil. The Spanish/Hispanic/Latino question is about ethnicity,
not race.
RACE INFORMATION (CHECK ALL THAT APPLY)
__ AMERICAN INDIAN (597) or __ ALASKAN NATIVE (015)
A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains a tribal affiliation or community
attachment.
__ ASIAN (621)
A person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian Subcontinent including, but not
limited to, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
__ NATIVE HAWAIIAN (653) or __ Other PACIFIC ISLANDER (681)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
__ WHITE/CAUCASIAN (800)
A person with origins in any of the original peoples of Europe,
North Africa, or the Middle East.
__ BLACK/AFRICAN-AMERICAN (870)
A personal having origins in any of the Black racial groups of Africa.
VETERAN STATUS (CHECK ALL THAT APPLY)
__ NOT A VETERAN
__ VIETNAM-ERA VETERAN (VV)
__ NON VIETNAM-ERA VETERAN (OV)
__ SPOUSE OF DECEASED VETERAN (SV)
__ DISABLED VETERAN (% OF DISABILITY ____) (DV) (DO)
DATES OF SERVICE: _________________________________
Vietnam-era Veteran: A person who served on active duty for more than 180 days, any part of which occurred between August 5, 1964 and May 7,
1975, and was discharged or released from duty with other than a dishonorable discharge.
Disabled Veteran: A person entitled to disability compensation under laws administered by the U.S. Department of Veterans Affairs for disability rated
at 30 percent or more, or rated at 10 or 20 percent in the case of a veteran who has been determined to have a serious employment handicap, or a person
whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.
DISABILITY INFORMATION
__ YES __ NO Do you have a physical, sensory, or mental condition that substantially limits any of your major life
functions, such as working, caring for yourself, walking, doing things with your hands, seeing, hearing, speaking, or
learning?
Disability definition: For Affirmative Action purposes, people with disabilities are persons with a permanent physical, mental, or sensory impairment
which substantially limits one or more major life activities. Physical, mental or sensory impairment means: (a) any physiological or neurological disorder or
condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems or functions; or (b) any mental or psychological disorders
such as mental retardation, organic brain syndrome, emotional or mental illness, or any specific learning disability. The impairment must be material
rather than slight, and permanent in that it is seldom fully corrected by medical replacement, therapy, or surgical means
.
I certify that this information is true and accurate to the best of my knowledge.
EMPLOYEE SIGNATURE: ________________________________________ DATE: __________________________________
RETURN COMPLETED FORM TO HUMAN RESOURCES
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signature
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Employer Signature
I have veried the information above using MRV or by contacting a DRS representative. I acknowledge that failure to properly report
a retiree to DRS can result in a liability to the employer.
Employer Signature Date
Employer Comments (optional)
Please enter any additional comments here. If you need more room, use the back of this form and check this box: c
Employee Information
Employer
Verication
Employee Name (Last, First, Middle) Social Security Number
Are you a retiree of one of Washington state’s retirement systems? If yes, which one(s)?
c Yes, _______________________________________________________________________________________ c No
c Yes c No
Are you a retiree of a separate retirement plan covered by the city of Seattle, Spokane or Tacoma?
If yes, which one(s)?
c Yes, _______________________________________________________________________________________ c No
If the employee checked yes,
stop. Contact ESS before
enrolling the employee in a
DRS retirement plan.
Are you currently employed by another public employer and contributing to a Washington state
retirement system? That is, will you be working at the same time for two public employers?
c Yes c No
If the employee checked yes,
stop. Contact ESS before
enrolling the employee in a
DRS retirement plan.
Employee Signature Date
Retirement Status
Verication
Employers can use this form to document
the retirement status of all new employees,
as required by RCW 41.50.139.
Contact Information for
Employer Support Services at DRS
360.664.7200, option 2
800.547.6657, option 6, option 2
employersupport@drs.wa.gov
Employer Instructions
RCW 41.50.139 requires employers to obtain, in writing, the retirement status of all new employees. Employers
can document retirement status through their own processes or by using this DRS form. If using this form,
follow these instructions:
• Ask the employee to complete and sign the Employee Information section below.
• Use Member Reporting Verication (MRV) to review the employee’s retirement status.
• Record the results in the Employer Verication section below.
• Determine whether the employee retired using the 2008 Early Retirement Factors. c Yes c No
If yes, contact DRS Employer Support Services (ESS) immediately.
• Use Retiree Return to Work (RRTW) Reporting Charts to review reporting instructions as necessary.
• Sign and date this form.
• Retain this form for 60 years.
*DRSMS147*
DRS MS 147 (5/16)
Clear Form
HR 6/2017 |HREFT
ABOUT YOUR PAYROLL FUNDS
Bellevue Community College Payroll Office: 425-640-1492
Edmonds Community College Human Resources Office: 425-640-1400
1. Employees have 2 options for receiving their payroll funds:
Direct Deposit (electronic funds transfer, EFT)
OR
Focus Card (Visa prepaid card)
2. You will receive a paper check the first payroll after submission of the Payment Authorization Form.
This check will be mailed to your home address via the U.S. Postal Service.
3. Some banks may post your automatic payroll deposit later than the hour the bank opens. Consult with your
bank for the time of day your funds will be available to you.
4. It is the employee’s responsibility to notify the payroll office of any bank or account information changes that
occur. Failure to do so may result in a delayed payment to the employee of up to 5 days after the pay date.
5. The Employee Earnings & Leave Web application will also show whether a Focus debit card or a direct deposit
was created for each payroll run. You can access your payroll information via the Employee Earning & Leave Web
application: https://transact.edcc.edu/empearnlv/
The Affordable Care Act (ACA) Notice of Health Insurance Marketplace/Coverage Options and Your Public Employees Benefits
Board (PEBB) Benefits
General Information
Beginning in 2014, most individuals will be required to have health insurance coverage. There will be a new way to buy health
insurance through the new health insurance Marketplace, also known as the Health Benefit Exchange. Washington Healthplanfinder
is the Marketplace serving Washington residents. This notice provides basic information about the Marketplace as well as PEBB
benefits offered by your employer and is intended to assist you in evaluating options for you and your family.
1. What is the Health Insurance Marketplace?
Under the ACA, every state must have a health insurance Marketplace to help people buy health insurance. The Marketplace
offers assistance to help you find and compare medical health insurance options offered by private companies. The Marketplace
will also help you find out if you qualify for premium tax credits or other financial assistance.
2. When does open enrollment begin?
Open enrollment for the Marketplace begins November 1, 2016 for coverage starting January 1, 2017.
3. Can I save money on my health insurance premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if you are not
eligible for PEBB medical plan
enrollment as an employee. The amount of premium savings in the Marketplace depends on your household income.
4. Does being eligible for an employer contribution for PEBB medical coverage affect eligibility for premium savings through the
Healthplanfinder? Yes.
● Employees eligible for employer contribution:
All eligible state employees receive an employer contribution for PEBB medical plan enrollment and are not allowed to
waive PEBB medical coverage to enroll in coverage through the Marketplace. All or a portion of this contribution may be
excluded from income for Federal and State income tax purposes. These employees should remain enrolled in their PEBB
medical plan.
State employees who are eligible to receive an employer contribution cannot use the employer contribution to purchase
coverage through the Marketplace, and will not be eligible for a premium tax credit if they purchase coverage through the
Marketplace.
However, if the cost of a PEBB health plan to cover you (and not any other members of your family) is more than 9.5% of
your household income for the year, or does not meet the “minimum value” standard set by the ACA, you may be eligible
for a tax credit or other financial assistance.
An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit
costs covered by the plan is no less than 60 percent of such costs.
● Employees not
eligible for employer contribution:
Employees who are not eligible for the employer contribution for PEBB medical plan enrollment should consider applying
for health benefits in the new Marketplace as they may qualify for a premium tax credit or other financial assistance. Your
payments for coverage through the Marketplace are made on an after-tax basis.
5. How do I get additional information about the Marketplace?
The Marketplace simplifies your search for health coverage by gathering the options available in your area in one place. You can
compare plans based on price, benefits, quality, and other features important to you before you make a choice.
Visit www.healthcare.gov
(with a live chat option) or also get help by phone, or in person.
Call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325).
6. How do I contact the Washington Healthplanfinder?
For help with your Washington Healthplanfinder application or to get answers about coverage, call our Customer Support
Center. Help is available in 175 languages. Language and disability accommodations are provided at no cost.
Toll-free: 1-855-923-4633
TTY: 1-855-627-9604
Hours: 8 a.m. to 8 p.m. Monday – Friday
Email: customersupport@wahbexchange.org
7. How do I get more information about PEBB benefits?
For more information about PEBB health plans offered by your employer, please check the Certificate of Coverage for your plan,
or contact your benefits office.
You can also find complete information about PEBB benefits at the PEBB website:
www.hca.wa.gov/pebb
Information about PEBB health coverage offered by your employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for
coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the
Marketplace application.
3. Employer name
Edmonds Community College
4. Employer Identification Number (EIN)
910825212
5. Employer address
20000 68
th
Ave West
6. Employer phone number
(425)640-1077
7. City
Lynnwood
8. State
WA
9. ZIP code
98036-5999
10. Who can we contact about employee health coverage at this job?
Debbie Lau (employees with last names N-Z, all PTF)
Denise Olson (employees with last names A-M, all Hourly)
11. Phone number (if different from above)
(425) 640-1077
(425) 640-1069
12. Email address
dlau@edcc.edu
Denise.Olson@edcc.edu
Information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
All employees.
Some employees.
Eligible employees are described in Washington Administrative Code 182-12-114:
(1)(a) An employee is eligible if he or she works an average of at least eighty hours per month and works for at least eight hours
in each month for more than six consecutive months.
(i)Upon employment: An employee is eligible from the date of employment if the employing agency anticipates the employee
will work according to the criteria in (a) of this subsection.
(2)(a) Seasonal employees are eligible if he or she works an average of at least eighty hours per month and works for at least
eight hours in each month of the season. A season is any recurring, cyclical period of work at a specific time of year that lasts
three to eleven months.
(b) Determining eligibility.
(i) Upon employment: A seasonal employee is eligible from the date of employment if the employing agency anticipates that he
or she will work according to the criteria in (a) of this subsection.
(ii) Upon revision of anticipated work pattern. If an employing agency revises an employee's anticipated work hours such that
the employee meets the eligibility criteria in (a) of this subsection, the employee becomes eligible when the revision is made.
(iii) Based on work pattern. An employee who is determined to be ineligible for benefits, but later works an average of at least
eighty hours per month and works for at least eight hours in each month and works for more than six consecutive months,
becomes eligible the first of the month following a six-month averaging period.
(c) Stacking of hours. As long as the work is within one state agency, employees may "stack" or combine hours worked in more
than one position or job to establish eligibility and maintain the employer contribution toward insurance coverage. Employees
must notify their employing agency if they believe they are eligible through stacking. Stacking includes work situations in which:
(i) The employee works two or more positions or jobs at the same time (concurrent stacking);
(ii) The employee moves from one position or job to another (consecutive stacking); or
(iii) The employee combines hours from a seasonal position or job to hours from a nonseasonal position or job. An employee
who establishes eligibility by stacking hours from a seasonal position or job with hours from a nonseasonal position or job shall
maintain the employer contribution toward insurance coverage under WAC 182-12-131(1).
(3)(a) Faculty "Half-time" means one-half of the full-time academic workload as determined by each institution, except that
half-time for community and technical college faculty employees is governed by RCW 28B.50.489.
Note: A change to the definition of full time, for community and technical college faculty, based on a collective bargaining
agreement may affect an employee’s eligibility for PEBB benefits. If eligibility is lost, COBRA coverage is available as described in
WAC 182-12-146.
(i) Upon employment: Faculty who the employing agency anticipates will work half-time or more for the entire instructional
year, or equivalent nine-month period, are eligible from the date of employment.
(ii) For faculty hired on quarter/semester to quarter/semester basis: Faculty who the employing agency anticipates will not
work for the entire instructional year, or equivalent nine-month period, are eligible at the beginning of the second consecutive
quarter or semester of employment in which he or she is anticipated to work, or has actually worked, half-time or more. Spring
and fall are considered consecutive quarters/semesters when first establishing eligibility for faculty that work less than half-time
during the summer quarter/semester.
(iii) Upon revision of anticipated work pattern: Faculty who receive additional workload after the beginning of the anticipated
work period (quarter, semester, or instructional year), such that their workload meets the eligibility criteria of (a)(i) or (ii) of this
subsection become eligible when the revision is made.
(b) Stacking. Faculty may establish eligibility and maintain the employer contribution toward insurance coverage by working as
faculty for more than one institution of higher education. Faculty workloads may only be stacked with other faculty workloads
to establish eligibility under this section or maintain eligibility under WAC 182-12-131(3). When a faculty works for more than
one institution of higher education, the faculty must notify his or her employing agencies that he or she works at more than one
institution and may be eligible through stacking
(4)(a) Elected and full-time appointed officials of the legislative and executive branches of state government are eligible for
PEBB benefits on the date his or her term begins. All other elected and full-time appointed officials of the legislative and
executive branches of state government are eligible on the date their terms begin or the date they take the oath of office,
whichever occurs first.
(5)(a) Justices and judges are eligible for PEBB benefits on the date they take the oath of office.
• With respect to dependents:
We do offer coverage.
We do not offer coverage.
Eligible dependents are described in Washington Administrative Code 182-12-260:
(1) Lawful spouse.
(2) Domestic partner. (a) Effective January 1, 2010, a state registered domestic partner, as defined in RCW 26.60.020(1). (b) A
domestic partner who was qualified under PEBB eligibility criteria as a domestic partner before January 1, 2010, and was
continuously enrolled under the subscriber in a PEBB health plan or life insurance.
(3) Children. Children are eligible up to age twenty-six except as described in subsection (i) of this section. Children are defined
as the subscriber's:
(a) Children as defined in RCW 26.26.101 establishment of parent-child relationship;
(b) Biological children;
(c) Stepchildren. The stepchild’s relationship to a subscriber (and eligibility as a PEBB dependent) ends, for purposes of this
rule, on the same date the subscriber’s legal relationship with the spouse or domestic partner ends through divorce, annulment,
dissolution, termination, or death;
(d) Legally adopted children;
(e) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of
the child;
(f) Children of the subscriber's state registered domestic partner;
(g) Children specified in a court order or divorce decree;
(h) Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber's spouse, or subscriber's
state registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child's official
residence with the custodian or guardian. "Children" does not include foster children for whom support payments are made to
the subscriber through the state department of social and health services foster care program; and
(i) Children of any age with a disability. Effective January 1, 2011, children of any age with a disability, mental illness, or
intellectual or other developmental disability, who are incapable of self-support, provided such condition occurs before age
twenty-six. Periodic certification is required.
(4) Parents.
(a) Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long as:
(i) The parent maintains continuous enrollment in PEBB medical;
(ii) The parent qualifies under the Internal Revenue Code as a dependent of the subscriber;
(iii) The subscriber continues enrollment in PEBB insurance coverage; and
(iv) The parent is not covered by any other group medical plan.
(b) Parents eligible under this subsection may be enrolled with a different health plan than that selected by the subscriber.
Parents may not add additional dependents to their insurance coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be
affordable, based on employee wages.
Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the
Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be
eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or
you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify
for a premium discount.
11/2016
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