Fillable Form I-9: Employment Eligibility Verification (Mississippi Delta Community College)

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Form I-9: Employment Eligibility Verification (Mississippi Delta Community College)

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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.
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)
click to sign
signature
click to edit
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.
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 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
)RUP85HY
0,66,66,33,(03/2<((6:,7++2/',1*(;(037,21&(57,),&$7(
(PSOR\HHV1DPH 661
(PSOR\HHV5HVLGHQFH
$GGUHVV
0DULWDO6WDWXV
(03/2<((
6LQJOH
)LOHWKLVIRUPZLWK\RXU
HPSOR\HU. Otherwise, you
must withhold Mississippi
income tax from the full
amount of your wages.
(03/2<(5
.HHSWKLVFHUWLILFDWHZLWK
\RXUUHFRUGV. If the
employee is believed to
have claimed excess
exemption, the Department
of Revenue should be
advised.
3HUVRQDO([HPSWLRQ$OORZHG
&/$,0<285:,7++2/',1*3(5621$/(;(037,21
$PRXQW&ODLPHG
Enter $6,000 as exemption . . . . f
0LVVLVVLSSL'HSDUWPHQWRI5HYHQXH
32 %R[
-DFNVRQ06
1XPEHUDQG6WUHHW &LW\RU7RZQ
6WDWH
=LS &RGH
&KHFN2QH
(a)
(b)
Spouse 127 employed: Enter $12,000
f
Spouse ,6 employed: Enter that part of
$12,000 claimed by you in multiples of
$500. See instructions 2(b) below .f
0DULWDO 6WDWXV
+HDGRI)DPLO\
Enter $9,500 as exemption. To qualify
as head of family, you must be single
and have a dependent living in the
home with you. See instructions 2(c)
and 2(d)below . . . . . . . . . . . .f
You may claim $1,500 for each dependent, other than
for taxpayer and spouse, who receives chief support
from you and who qualifies as a dependent for Federal
income tax purposes.
* A head of family may claim $1,500 for each
dependents excluding the one which qualifies you
as head of family. Multiply number of dependents
claimed by you by $1,500. Enter amount claimed ...
f
'HSHQGHQWV
1XPEHU&ODLPHG
$JHDQG
%OLQGQHVV
Age 65 or older Husband Wife Single
Blind Husband Wife Single
Multiply the number of blocks checked by $1,500.
Enter the amount claimed . . . . .f
1RWH: No exemption allowed for age or blindness
for dependents.
7KHSHUVRQDOH[HPSWLRQVDOORZHG
(a) Single Individuals $6,000 (d) Dependents $1,500
(b) Married Individuals (Jointly) $12,000 (e) Age 65 and Over $1,500
(c) Head of family $9,500 (f) Blindness $1,500
&ODLPLQJSHUVRQDOH[HPSWLRQV
(a) Single Individuals enter $6,000 on Line 1.
0LOLWDU\6SRXVHV
5HVLGHQF\5HOLHI$FW
([HPSWLRQIURP0LVVLVVLSSL
:LWKKROGLQJ
INSTRUCTIONS
727$/$028172)(;(037,21&/$,0('/LQHVWKURXJKf
1RWH: No exemption allowed for age or blindness
for dependents.
Additional dollar amount of withholding per pay period if
agreed to by your employer . . . . . . . . . . . . . . . . .f
If you meet the conditions set forth under the Service Member
Civil Relief, as amended by the Military Spouses Residency
Relief Act, and have no Mississippi tax liability, write
([HPSW on Line 8. You must attach a copy of the Federal
Form DD-2058 and a copy of your Military Spouse ID Card to
this form so your employer can validate the exemption claim..f
I declare under the penalties imposed for filing false reports that the amount of exemption claimed on this
certificate does not exceed the amount to which I am entitled or I am entitled to claim exempt status.
(PSOR\HHV6LJQDWXUH 'DWH
(e) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if
either or both have reached the DJHRI before the close of the taxable year. No
additional exemption is authorized for dependents by reason of age. Check applicable
blocks on Line 5.
(d) An additional exemption of $1,500 may generally be claimed for each dependent of the
taxpayer. A dependent is any relative who receives chief support from the taxpayer and
who qualifies as a dependent for Federal income tax purposes. Head of family individuals
may claim an additional exemption for each dependent excluding
the one which is required
for head of family status. For example, a head of family taxpayer has 2 dependent children
and his dependent mother living with him. The taxpayer may claim 2 additional exemptions.
Married or single individuals may claim an additional exemption for each dependent, but
(c) Head of Family
A head of family is a single individual who maintains a home which is the principal place of
abode for himself and at least one other dependent. Single individuals qualifying as a head
of family enter $9,500 on Line 3. If the taxpayer has more than one dependent, additional
exemptions are applicable. See item (d).
(b) Married individuals are allowed a joint exemption of $12,000.
If the spouse is not employed, enter $12,000 on Line 2(a). If the spouse is employed, the
exemption of $12,000 may be divided between taxpayer and spouse in any manner they
choose - in multiples of $500. For example, the taxpayer may claim $6,500 and the spouse
claims $5,500; or the taxpayer may claim $8,000 and the spouse claims $4,000. The total
claimed by the taxpayer and spouse may not exceed $12,000. Enter amount claimed by
you on Line 2(b).
(f) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if
either or both are EOLQG. No additional exemption is authorized for dependents by reason of
blindness. Check applicable blocks on Line 5. Multiply number of blocks checked on Line 5
by $1,500 and enter amount of exemption claimed.
VKRXOGQRW include themselves or their spouse. Married taxpayers may divide the number of their
dependents between them in any manner they choose; for example, a married couple has 3 children
who qualify as dependents. The taxpayer may claim 2 dependents and the spouse 1; or the taxpayer
may claim 3 dependents and the spouse none. Enter the amount of dependent exemption on Line 4.
7RWDO([HPSWLRQ&ODLPHG
Add the amount of exemptions claimed in each category and enter the total on Line 6. This
amount will be used as a basis for withholding income tax under the appropriate withholding
tables.
$1(:(;(037,21&(57,),&$7(0867%(),/(':,7+<285(03/2<(5:,7+,1
'$<6$)7(5$1<&+$1*(,1<285(;(037,2167$786.
3(1$/7,(6 $5(,0326(')25:,//)8//<6833/<,1*)$/6(,1)250$7,21
,)7+((03/2<(()$,/672),/($1(;(037,21&(57,),&$7(:,7++,6
(03/2<(5,1&20(7$;0867%(:,7++(/'%<7+((03/2<(521727$/
:$*(6:,7+2877+(%(1(),72)(;(037,21.
. To comply with the Military Spouse Residency Relief Act (PL111-97) signed on November
11, 2009.
qp pp y
may claim an additional exemption for each dependent excluding
the one which is required
for head of family status. For example, a head of family taxpayer has 2 dependent children
and his dependent mother living with him. The taxpayer may claim 2 additional exemptions.
Married or single individuals may claim an additional exemption for each dependent, but
(03/2<(5,1&20(7$;0867%(:,7++(/'%<7+((03/2<(521727$/
:
$
*
(6
:
,
7
+
2
8
7
7
+
(
%(1(),72)(;(037,21.
. To comply with the Military Spouse Residency Relief Act (PL111-97) signed on November
11, 2009.
Mississippi New Hire Reporting Form
Mail completed form to: Mississippi State Directory of New Hires
P.O. Box 312
Holbrook, MA 02343
Or fax completed form to: 1-800-937-8668
Effective October 1, 1997, all Mississippi employers (or independent contractors) are required to report certain
information about personnel who have been newly hired, rehired, or have returned to work. Reports must be made
within 15 calendar days from date of hire. Employers must either (1) complete this form, or (2) submit a copy of
the worker’s IRS W-4 form with the “other information section” completed on this form, or (3) submit the
information by magnetic tape or floppy diskette. To submit new hire reports electronically, call 1-800-241-1330 to
obtain information.
Below, please complete all employer information
EMPLOYER INFORMATION
*Federal Employer Identification Number (FEIN):
!! - !!!!!!!
(Please the same FEIN for which listed employee(s) quarterly wages will be reported under)
State Employer Identification Number (SEIN): !! - !!!!!!!
*Employer Name: _________________________________________ DBA: ___________________________
*Address: _________________________________________________________________________________
__________________________________________________________________________________________
(Please indicate the address where the Income Withholding Order will be sent)
*City: ___________________________ *State: _________ *Zip Code: ____________ +4: _________
Contact Name: _____________________________ Phone: ______________________
_____
Email: ____________________________________
Below, please complete one entry for each new employee
EMPLOYEE INFORMATION
*Social Security Number:
!!! - !! - !!!! Gender (circle one): Male Female
*First Name: ________________________________________ Middle: __________________________
*Last Name: _____
___________________________________
*Employee Address: ________________________________________________________________________
_________________________________________________________________________________________
*City: ___________________________ *State: _________ *Zip Code: ____________ +4: _________
Date of Birth: _____/_____/_______ *Date of Hire: _____/_____/_______ State of Hire _______
Employee Salary: ____________________ Payment Frequency
(circle one): Weekly Bi-weekly Monthly Annually
Is this employee eligible for medical insurance
(circle one)? Yes No
For information please visit our website at www.ms-newhire.com or call us toll-free at 1-800-241-1330
6
4
6 0 0 1 1 0 1
Mississippi Delta Community College
B
usiness Office
P.
O. Box 668
Moor
head
MS
3
8761
0
668
Sarah Hanson
662-246-6313
shanson@msdelta.edu
0 6 5 0 6 2 0
6
9
DRUG FREE ENVIRONMENT POLICY
Mississippi Delta Community College has adopted and implemented a program to prevent the
unlawful possession, use, or distribution of illicit drugs and alcohol by its students and
employees on school premises as part of its activities in compliance with the Drug-Free Schools
and Communities Acts of 1989 Public Law 101-226.
Mississippi Delta Community College is committed to maintaining a drug-free environment in
conformity with state and federal laws as set forth in the Uniform Controlled Substances Law of
the State of Mississippi.
Illicit drugs are defined in Section 202 of the Controlled Substance Act; and the Mississippi
Uniform Controlled Substance Law, Mississippi Code supplement (1989). Alcoholic beverages
are defined in Sections 41-29-139, 141, 61-1-37, 81, 97-29-7 of the Mississippi Code Annotated
for 1972 (1989 Supplement).
As specified in Section 41-29-142, 41-29-139, 61-1-81, 97-29-47 of the Mississippi Code
Supplement, legal sanctions are applied to the following actions: possession of alcohol on
college property; public drunk on college property; utilization of false ID to obtain alcohol;
driving under the influence of alcohol; possession of illicit drugs, sale of illicit drugs near
schools; possession of paraphernalia; and sale of paraphernalia. Sanctions range from fines of
$25 to $1 million and jail sentences of 30 days in the county jail to 30 years in the state
penitentiary.
Mississippi Delta Community College strictly prohibits the unlawful possession, use, or
distribution of illicit drugs including drug paraphernalia, and alcohol on campus and during any
college sponsored activities.
Employees who are guilty of violating the above stated policy can expect to face disciplinary
action, which may include:
a) Suspension as an employee from the college.
b) Referral to law enforcement agency.
c) Termination from employment.
d) Any other disciplinary action deemed appropriate by the college president or the
Board of Trustees.
________________________________________ ________________________
Employee Signature Date
EMPLOYMENT INFORMATION
FOR
PART-TIME EMPLOYEES
Mississippi Delta Community College is
required
to
withhold
retirement
from
all
employees that are
active
members
(not retired) with PERS. Please read the following statements, check the appropriate statement, and sign the
form.
I am NOT a member of the MS Public Employees’ Retirement System.
I am an
INACTIVE
member of the MS Public Employees’ Retirement System.
I am a
RETIRED
member of the MS Public Employees’ Retirement System.
If you checked the RETIRED member statement then answer the following:
Date of Retirement: _________________________________________________
If you are employed part-time with another PERS covered agency other than MDCC,
please provide the following:
Name of Employer: ______________________________________________
Contact Person: _________________________________________________
Address/Phone number: ___________________________________________
_______________________________________________________________
_______________________________________________________________
I am a CURRENT ACTIVE member of the MS Public Employees’ Retirement System
Please provide name of current FULL-TIME employer:
PRINT NAME SIGNATURE DATE
IMPORTANT:
If you are employed with more than one covered agency, it is your responsibility to fill in
form 4B with each employer. You cannot earn more than your allowed amount (combined
total from both employers) listed in the employer certification section ‘A or ‘B on form 4B.
Violation could result in loss of PERS benefits and repayment of all benefits drawn to date
plus interest. (PERS Website:
www.pers.state.ms.us
/ Click Member Services / Forms
Library.
PRINT NAME SIGNATURE DATE
MISS. CODE ANN. §25-1-113
EMPLOYEE CERTIFICATION AND AUTHORIZATION STATEMENT
NOTICE
Section 25-1-113, Mississippi Code of 1972, as amended, prohibits the hiring for public employment of individuals
who have been convicted of or plead guilty to the unlawful taking or misappropriation of public funds effective July
1, 2013. Effective July 1, 2014, the State cannot continue to employ a person who has been convicted or pled guilty
to the unlawful misappropriation of public funds. Specifically, Section 25-1-113, has been amended to read as
follows:
The State and any county, municipality, or any other political subdivision may not employ or continue to employ a
person who has been convicted or pled guilty in any court of this state, another state, or in federal court of any
felony in which public funds were unlawfully taken, obtained or misappropriated in the abuse or misuse of the
person’s office or employment or money coming into the person’s hands by virtue of the person’s office or
employment.
EMPLOYEE CERTIFICATION AND AUTHORIZATION
I have been notified that as an employee of the State of Mississippi I cannot have been convicted of or pled guilty
in any court of this state, another state, or in federal court of any felony in which public funds were unlawfully
taken, obtained or misappropriated in the abuse or misuse of my office or employment or money coming into my
hands by virtue of my office or employment. I understand that any conviction of embezzlement will disqualify me
from employment with the State of Mississippi and result in my termination.
I swear or affirm that I have never been convicted or pled guilty in any court of this state, another state, or in
federal court of any felony in which public funds were unlawfully taken, obtained or misappropriated by the abuse
or misuse of any office or employment or money coming into my hands by virtue of my office or employment.
I hereby authorize the Mississippi Community College Board to conduct a background check of my criminal history
at any time as a condition of and/or subsequent to my employment. I understand and acknowledge that I may
revoke my permission for such background check. In such case, no background check investigation will be done
and my employment may be terminated. I further understand and acknowledge that should the criminal
background check occur and it establishes that I have been convicted or pled guilty to misuse of public funds in
violation of Section 25-1-113, my employment will terminate and I will have no recourse against the Mississippi
Community College Board. In addition, I agree to hold harmless and indemnify Mississippi Community College
Board, its members and employees, for any loss due to my employment being found to be in violation of Section
25-1-113.
__________________________________________ ______________________
Signature of Employee Date
__________________________________________ ______________________
Employee’s Name – Printed Date of Birth
__________________________________________
Social Security Number
__________________________________________ _______________________
Signature of Witness Date
__________________________________________
Name of Witness - Printed
Non-Covered Employment Acknowledgment
Form 4A – Revised 12/1/2013
Complete only if employee is not receiving PERS service retirement benefits and is not contributing to PERS through another employer.
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Employee Information
First Na
me: _______________________________________ MI: ______ Last Name: ______________________________________ Gender: M F
Social Security No.: __________________________ Birth Date mm/dd/ccyy: _________________ E-Mail: ______________________________________
Mailing Address: ___________________________________________ City: ___________________________ State: ________ Zip: _______________
Phone: _______________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Employee Acknowledgment
I hereby acknowledge that I am not receiving service retirement benefits from PERS and that my employment does not meet the eligibility requirements of
PERS Board of Trustees Regulation 25, Eligibility of Part-time Employees for State Retirement Annuity Service Credit, and PERS Board of Trustees
Regulation 36, Eligibility for Membership in the Public Employees’ Retirement System of Mississippi (PERS), and that I, therefore, am not eligible for
coverage for this employment under the provisions of PERS.
If an authorized representative signs this form, attach a copy of the durable power of
attorney, conservatorship or guardianship papers, or other legal documents as proof of authority to sign this form.
Employee’s Sign
ature: _____________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification – This section must be completed by an authorized employer representative, not the employee.
Employee’s Position Held/Job Title: _____________________________________________________________________________________________
Employee’s Hire Date mm/dd/ccyy: ______________________________ Employee’s Termination Date mm/dd/ccyy: ____________________________
Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________
As employer representative, I understand that wages earned and paid to the above named individual during this period of employment will not be subject to
withholding for state retirement. I further understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a
retirement plan administered by PERS in an attempt to defraud the plan may be subject to criminal prosecution. With that understanding, I certify that the
above information is true and correct and that employment in this position does not meet the eligibility requirements of PERS Board of Trustees Regulation
25, Eligibility of Part-time Employees for State Retirement Annuity Service Credit, and PERS Board of Trustees Regulation 36, Eligibility for Membership in
the Public Employees’ Retirement System of Mississippi (PERS).
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5262, fax www.pers.ms.gov
Mississippi Delta Community College
620
000
Sarah Hanson
Personnel Coordinator
(662) 246-6313
(662) 246-6324 shanson@msdelta.edu
0
Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.5261, fax www.pers.ms.gov
Reemployment of PERS Service Retiree Certification/Acknowledgement
Form 4B – Revised 11/17/2017
Please print or type in black ink. A Form 4B, Reemployment of PERS Service Retiree Certification/Acknowledgement, should be submitted each
fiscal year (July 1 – June 30) of reemployment. See Regulation 34, Reemployment after Retirement, for rules governing reemployment.
Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Retiree Information
First Name: _____________________________________ MI: _________ Last Name: ______________________________________________________
Mailing Address: ________________________________________________ City: ___________________________ State: _______ Zip: _____________
Social Security No.: _______________________________E-Mail: _______________________________________________________________________
Phone: ________________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Position/Agency from which Retired: _______________________________________________ Retirement Date mm/dd/ccyy: ______________________
Annual Retiree Acknowledgement and Election – Please check one.
I hereby acknowledge that I have read, understand, and agree to comply with the provisions for reemployment as outlined in PERS Board Regulation 34,
R
eemployment after Retirement, which stipulates that I must be retired at least 90 days or I forfeit my retirement benefit. With that understanding, I make the
following annual election in accordance with Miss. Code Ann. § 25-11-127 (1972, as amended):
A. ____ I hereby elect to be employed by a covered employer for a period of time not to exceed one-half of the normal working days or hours for the full-time
equivalent position during the state fiscal year indicated in Section 3, and I will receive no more than one-half of the salary in effect for the position at
the time of employment. The normal working days or hours for the full–time equivalent position are ______ days or ______ hours and I will work no
more than _______ days or ______ hours during the state fiscal year indicated in Section 3. The full-time annual salary authorized for this position is
$____________________ and I will earn no more than $____________________ during the state fiscal year indicated in Section 3.
B. ____ I hereby elect to earn an annual salary that will not exceed 25 percent of the final average compensation used in calculating my service retirement
allowance. My final average compensation at retirement was $____________________ and I will earn no more than $_____________________
from all PERS-covered employers during the state fiscal year indicated below.
Retiree’s Signature: _______________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification – This section should be completed by an authorized employer representative, not the retiree.
I hereby certify that the above-
named individual, who is a service retiree receiving benefits from PERS, is employed in the below-named position in
accordance with the reemployment provisions as authorized in Miss Code Ann. § 25-11-127 (1972 as amended) and in accordance with the provisions of
PERS Regulation 34, Reemployment after Retirement. I understand that wages earned and paid to the above-named individual during this period of
employment will be reported in accordance with reporting requirements prescribed by PERS and the applicable employer contributions on the wages
actually paid must be submitted. I further understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a
retirement plan administered by PERS in an attempt to defraud the plan may be subject to criminal prosecution, and with that understanding, I certify that the
below information is true and correct.
Retiree’s
Position /Job Title: _________________________________________________ Fiscal Year of Reemployment (July 1 - June 30): ________
Retiree’s Hire Date mm/dd/ccyy: ___________________________________Termination Date mm/dd/ccyy: ____________________________________
Retiree Employed through Third Party: No Yes Name of Third Party: _____________________________________________________________
Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: _________________________ E-Mail: __________________________________
Employer Representative’s Signature: _________________________________________________________ Date mm/dd/ccyy: _____________________
Mississippi Delta Commu
nity College
0620 000
Sar
ah Hanson
Personnel Coordinator
(662) 246-6313
(662) 246-6324
shanson@msdelta.edu
MISSISSIPPI DELTA COMMUNITY COLLEGE
Office of Information Technology
it@msdelta.edu
662.246.6330
Fax:
662.246.6431
M E M O R A N D U M
TO: New MDCC Employee
FROM: Office of Information Technology
Welcome to the Trojan family!
Attached are several documents: the Information Network Resources Policies and Procedures
that were approved by the Board of Trustees, an Employee Use Agreement, the User Access
Request Form, and some various instructions and help documents.
Please read carefully & complete the following tasks.
1. Read the
Information Network Resources P
olicies
and
P
rocedures.
2.
S
ign
& date t
h
e
Employee
Use
Agreement.
Also
,
p
lease neatly
p
rint yo
u
r name
u
nder
your signature, as some signatures are not very readable.
3. Complete the User
Access Request
Form.
4. Return the signed
Employee
Use
Agreement
and the completed User
Access
Request
Form to:
Mississippi Delta Community College
Attn: Brenda Vanlandingham, Human Resources
P.O. Box 668
Moorhead, MS 38761
5. Keep all other documents for your personal reference.
We will notify your supervisor of your username, email address, and your employee ID number
so they can let you know when you access has been setup.
Please be sure to check your email messages regularly, and keep your message box “cleaned up”
as you are limited to space for your e-mail messages.
If you have any questions, feel free to contact our office at 662.246.6330 or by e-
mailing it@msdelta.edu.
MISSISSIPPI DELTA COMMUNITY
COLLEGE
INFORMATION NETWORK
RESOURCES
POLICIES &
PROCEDURES
I. INTRODUCTION AND PURPOSE
The purpose of the MDCC Information Network is to support the overall educational mission of the
college, in accordance with college policies. Access to the network and its resources is a privilege.
Network users must respect the rights of others and the integrity of the components of the
network.
This policy governs the use of all computers, computer-based networks, and related hardware and
software at Mississippi Delta Community College. Under federal statutes and the sections of the
Mississippi code that regulates the use of these resources, the college is required to ensure that this
equipment and software are used properly, and for the purpose for which state funds were expended.
The intent of this policy is to allow maximum freedom of use consistent with state and federal law,
college policy and a productive work environment.
II. SCOPE
This policy applies to all college faculty, staff, administrators, students, and members of the community
who use the College network resources. It covers all computing hardware that is connected to the
network, including microcomputers, printers, etc. It also includes all network infrastructure: data
wiring and fiber optic cable, routers, switches, hubs, servers, data connectors, and all other associated
hardware and materials.
The following types of software are covered under this policy: operating systems, network
software, compilers, and all instructional and application software defined as “supported by the
college”.
The following categories of data systems are included: the administrative and student information
system and data that have been collected or generated by the college. Not covered is software or
data that the college does not support, even though such may be stored on college hardware and/or
used by individual departments.
III. GENERAL STATEMENTS
A. Training -- Training is provided for administration, faculty and staff as new hardware, software and
services are made available. Prior to receiving access to the network, each employee must
demonstrate a satisfactory level of proficiency in certain areas such as proper use of passwords,
how to access the Internet, e-mail, administrative software, and other application software.
Administration, faculty and staff are encouraged to attend workshops and classes at off-site
locations provided sufficient funds are available in the departmental budgets.
Training will be made available to the employee at the time of employment.
B. Network Access -- Network access is controlled by passwords, and the level of access
granted is determined by a user's job-related or educational requirements.
1. User names and Passwords -- Users will be assigned a user name and password
which should not be disclosed. User names will follow a naming convention
developed by the Office of Information Technology. Passwords must be at least
eight positions in length. The recommended length is eight to twelve positions.
Passwords must contain an upper case character, a lower case character and must
contain at least one number, and may not contain spaces. The password should
not contain the user’s account name or parts of the user’s full name. Users will be
required to change passwords periodically. The password can not be the same as
the last four used passwords. Requests for new user names and passwords should
be submitted and approved using the User Access Request Form. Requests for
user names and passwords to be deleted from the computer system when an
employee is terminated should be submitted and approved using the College’s
Employee Departure Form.
2. Accounts -- Network accounts for employees are managed by the Office of
Information Technology staff. Requests for establishment or modification of
employee accounts must be approved at the Dean/Director level or above. Specific
access granted to an employee account is subject to approval by the appropriate
Dean/Director with the guidance of the Director of Information Technology.
Removal of an account occurs when the owner is no longer an employee of the
college, or when disciplinary action is indicated. It is the responsibility of the
employee’s supervisor to notify Information Technology staff within 24 hours of an
account holder's separation from service. Student accounts and public accounts
must be requested and maintained
by the appropriate department under the supervision of Information Technology
staff.
C. Ethical Use -- The network is for official college use only and must not be used for personal
business, profit-making ventures, political activities, or to harass or offend anyone. Some
employees will be given access to the student information systems and/or other
administrative systems. The confidentiality of these records is governed by the federal
Family Education Rights and Privacy Act of 1974 (a.k.a. Buckley Amendment, FERPA). All
information is confidential, and students have a right to expect that their scholastic records
are being properly supervised and maintained. Requests for disclosure of this information
must be approved by the appropriate administrative officer.
D. Security -- All information is property of Mississippi Delta Community College, and use or
distribution is prohibited without approval of the appropriate department. Information
should be protected against unauthorized access and/or destruction. A backup copy of
administrative information is made daily. It is recommended that each user make a
backup copy of information on individual personal computers frequently. A disaster
recovery plan is maintained by the Office of Information Technology. Users should not
leave a terminal/computer unattended while signed on. A secure off-site facility will be
provided for storage of backups, user documentation, copies of disaster plan, and critical
forms. The college attempts to protect the network from intrusion from within and
without. All suspected attempts to violate network security must be reported to a the
Director of Information Technology as soon as possible. If it is determined that a breech in
network security has compromised sensitive information, the President of the college may
request the aid of law enforcement to handle the investigation. The Office of Information
Technology will periodically check for, and follow up on, security violations.
E. Disaster Recovery Plan – The Office of Information Technology maintains a Disaster
Recovery Plan. All programs, files, folders, configuration and security information is saved
on a daily basis. Backup of individual personal computers is the responsibility of the
individual user.
F. Software Supported by the College -- -Software standards will be established and distributed by
the Office of Information Technology. Only approved software will be supported and
maintained. The support and maintenance of other software will be the responsibility of the
user. Computer software should be properly registered to obtain updates and protect
warranties or other legal rights.
G. Computer Hardware -- Computer hardware should not be relocated or have components
added or removed without coordination with the Office of Information Technology.
H. User requests -- All requests for services which fall within the realm of the Office of
Information Technology (telephones, e-mail, hardware, software, programming, network
services and support, Internet access) should be submitted by the appropriate supervisor
using the TrackIt System. The request will be directed to the proper Office of Information
Technology personnel for resolution.
I. Web Site – The college will operate a web site for the purposes of recruiting and disseminating
college information. This service will be operated and maintained by the Webmaster. All
requests concerning this area should be directed to the Webmaster.
J. Access to the Internet - The college provides Internet access through the college network to all
employees having a network account. Student Internet access is through the individual
instructional departmental laboratories, learning centers, and computer classrooms.
Community access is through the learning centers and open labs as approved by the college.
Internet access is intended only for official college business. The college discourages personal
use of the Internet through the college network, especially during the normal business hours.
The college does not condone access to sites which contain pornography and other sexually
explicit material. The use of the Internet for political purposes, illegal activity, profit-making
ventures, or the harassment of individuals or organizations is considered a violation of college
policy. Users should be aware that our system logs all Internet sites which are accessed
through the network. This information will be monitored on a regular basis through normal
network maintenance and to investigate abuse of the resource.
K. E-Mail -- An e-mail account is provided for each employee who has a network account. As
with Internet access, e-mail is intended only for official college business and not for illegal
activity, personal profit-making ventures, political purposes, or to harass any person or
organization. E-mail is, by definition, public, and is subject to review by college officials
without prior notification. Users are responsible for maintaining their e-mail accounts and
removing old messages.
L. Agreement -- Every employee who uses the network is required to read and sign the
“Information Network Resources Use Agreement”.
M. Sanctions --
1. Employees -- An employee found guilty of violating the terms of the “Information
Network Resources Use Agreement” is subject to sanctions. If misuse of the network by
an employee threatens the stability of the network, the Director of Information
Technology will suspend network privileges immediately. Additional sanctions could
include reprimand by the appropriate supervisor, dismissal, criminal prosecution or any
other sanction as outlined in the college’s Policies and Procedures Manual.
2. Students -- A student found guilty of misuse of the network is subject to loss of network
privileges, criminal prosecution, or any other disciplinary action described in the MDCC
Catalog.
3. Public -- A member of the public found guilty of misuse of the network is subject to loss
of network privileges and/or criminal prosecution.
MISSISSIPPI DELTA COMMUNITY COLLEGE
Office of Information Technology
it@msdelta.edu
662.246.6330
Fax:
662.246.6431
M E M O R A N D U M
TO: New MDCC Employee
FROM: Office of Information Technology
Welcome to the Trojan family!
Attached are several documents: the Information Network Resources Policies and Procedures
that were approved by the Board of Trustees, an Employee Use Agreement, the User Access
Request Form, and some various instructions and help documents.
Please read carefully & complete the following tasks.
1. Read the
Information Network Resources P
olicies
and
P
rocedures.
2.
S
ign
& date t
h
e
Employee
Use
Agreement.
Also
,
p
lease neatly
p
rint yo
u
r name
u
nder
your signature, as some signatures are not very readable.
3. Complete the User
Access Request
Form.
4. Return the signed
Employee
Use
Agreement
and the completed User
Access
Request
Form to:
Mississippi Delta Community College
Attn: Human Resources
P.O. Box 668
Moorhead, MS 38761
5. Keep all other documents for your personal reference.
We will notify your supervisor of your username, email address, and your employee ID number
so they can let you know when you access has been setup.
Please be sure to check your email messages regularly, and keep your message box “cleaned up”
as you are limited to space for your e-mail messages.
If you have any questions, feel free to contact our office at 662.246.6330 or by e-
mailing it@msdelta.edu.
MISSISSIPPI DELTA COMMUNITY
COLLEGE
INFORMATION NETWORK
RESOURCES
POLICIES &
PROCEDURES
I. INTRODUCTION AND PURPOSE
The purpose of the MDCC Information Network is to support the overall educational mission of the
college, in accordance with college policies. Access to the network and its resources is a privilege.
Network users must respect the rights of others and the integrity of the components of the
network.
This policy governs the use of all computers, computer-based networks, and related hardware and
software at Mississippi Delta Community College. Under federal statutes and the sections of the
Mississippi code that regulates the use of these resources, the college is required to ensure that this
equipment and software are used properly, and for the purpose for which state funds were expended.
The intent of this policy is to allow maximum freedom of use consistent with state and federal law,
college policy and a productive work environment.
II. SCOPE
This policy applies to all college faculty, staff, administrators, students, and members of the community
who use the College network resources. It covers all computing hardware that is connected to the
network, including microcomputers, printers, etc. It also includes all network infrastructure: data
wiring and fiber optic cable, routers, switches, hubs, servers, data connectors, and all other associated
hardware and materials.
The following types of software are covered under this policy: operating systems, network
software, compilers, and all instructional and application software defined as “supported by the
college”.
The following categories of data systems are included: the administrative and student information
system and data that have been collected or generated by the college. Not covered is software or
data that the college does not support, even though such may be stored on college hardware and/or
used by individual departments.
III. GENERAL STATEMENTS
A. Training -- Training is provided for administration, faculty and staff as new hardware, software and
services are made available. Prior to receiving access to the network, each employee must
demonstrate a satisfactory level of proficiency in certain areas such as proper use of passwords,
how to access the Internet, e-mail, administrative software, and other application software.
Administration, faculty and staff are encouraged to attend workshops and classes at off-site
locations provided sufficient funds are available in the departmental budgets.
Training will be made available to the employee at the time of employment.
B. Network Access -- Network access is controlled by passwords, and the level of access
granted is determined by a user's job-related or educational requirements.
1. User names and Passwords -- Users will be assigned a user name and password
which should not be disclosed. User names will follow a naming convention
developed by the Office of Information Technology. Passwords must be at least
eight positions in length. The recommended length is eight to twelve positions.
Passwords must contain an upper case character, a lower case character and must
contain at least one number, and may not contain spaces. The password should
not contain the user’s account name or parts of the user’s full name. Users will be
required to change passwords periodically. The password can not be the same as
the last four used passwords. Requests for new user names and passwords should
be submitted and approved using the User Access Request Form. Requests for
user names and passwords to be deleted from the computer system when an
employee is terminated should be submitted and approved using the College’s
Employee Departure Form.
2. Accounts -- Network accounts for employees are managed by the Office of
Information Technology staff. Requests for establishment or modification of
employee accounts must be approved at the Dean/Director level or above. Specific
access granted to an employee account is subject to approval by the appropriate
Dean/Director with the guidance of the Director of Information Technology.
Removal of an account occurs when the owner is no longer an employee of the
college, or when disciplinary action is indicated. It is the responsibility of the
employee’s supervisor to notify Information Technology staff within 24 hours of an
account holder's separation from service. Student accounts and public accounts
must be requested and maintained
by the appropriate department under the supervision of Information Technology
staff.
C. Ethical Use -- The network is for official college use only and must not be used for personal
business, profit-making ventures, political activities, or to harass or offend anyone. Some
employees will be given access to the student information systems and/or other
administrative systems. The confidentiality of these records is governed by the federal
Family Education Rights and Privacy Act of 1974 (a.k.a. Buckley Amendment, FERPA). All
information is confidential, and students have a right to expect that their scholastic records
are being properly supervised and maintained. Requests for disclosure of this information
must be approved by the appropriate administrative officer.
D. Security -- All information is property of Mississippi Delta Community College, and use or
distribution is prohibited without approval of the appropriate department. Information
should be protected against unauthorized access and/or destruction. A backup copy of
administrative information is made daily. It is recommended that each user make a
backup copy of information on individual personal computers frequently. A disaster
recovery plan is maintained by the Office of Information Technology. Users should not
leave a terminal/computer unattended while signed on. A secure off-site facility will be
provided for storage of backups, user documentation, copies of disaster plan, and critical
forms. The college attempts to protect the network from intrusion from within and
without. All suspected attempts to violate network security must be reported to a the
Director of Information Technology as soon as possible. If it is determined that a breech in
network security has compromised sensitive information, the President of the college may
request the aid of law enforcement to handle the investigation. The Office of Information
Technology will periodically check for, and follow up on, security violations.
E. Disaster Recovery Plan – The Office of Information Technology maintains a Disaster
Recovery Plan. All programs, files, folders, configuration and security information is saved
on a daily basis. Backup of individual personal computers is the responsibility of the
individual user.
F. Software Supported by the College -- -Software standards will be established and distributed by
the Office of Information Technology. Only approved software will be supported and
maintained. The support and maintenance of other software will be the responsibility of the
user. Computer software should be properly registered to obtain updates and protect
warranties or other legal rights.
G. Computer Hardware -- Computer hardware should not be relocated or have components
added or removed without coordination with the Office of Information Technology.
H. User requests -- All requests for services which fall within the realm of the Office of
Information Technology (telephones, e-mail, hardware, software, programming, network
services and support, Internet access) should be submitted by the appropriate supervisor
using the TrackIt System. The request will be directed to the proper Office of Information
Technology personnel for resolution.
I. Web Site – The college will operate a web site for the purposes of recruiting and disseminating
college information. This service will be operated and maintained by the Webmaster. All
requests concerning this area should be directed to the Webmaster.
J. Access to the Internet - The college provides Internet access through the college network to all
employees having a network account. Student Internet access is through the individual
instructional departmental laboratories, learning centers, and computer classrooms.
Community access is through the learning centers and open labs as approved by the college.
Internet access is intended only for official college business. The college discourages personal
use of the Internet through the college network, especially during the normal business hours.
The college does not condone access to sites which contain pornography and other sexually
explicit material. The use of the Internet for political purposes, illegal activity, profit-making
ventures, or the harassment of individuals or organizations is considered a violation of college
policy. Users should be aware that our system logs all Internet sites which are accessed
through the network. This information will be monitored on a regular basis through normal
network maintenance and to investigate abuse of the resource.
K. E-Mail -- An e-mail account is provided for each employee who has a network account. As
with Internet access, e-mail is intended only for official college business and not for illegal
activity, personal profit-making ventures, political purposes, or to harass any person or
organization. E-mail is, by definition, public, and is subject to review by college officials
without prior notification. Users are responsible for maintaining their e-mail accounts and
removing old messages.
L. Agreement -- Every employee who uses the network is required to read and sign the
“Information Network Resources Use Agreement”.
M. Sanctions --
1. Employees -- An employee found guilty of violating the terms of the “Information
Network Resources Use Agreement” is subject to sanctions. If misuse of the network by
an employee threatens the stability of the network, the Director of Information
Technology will suspend network privileges immediately. Additional sanctions could
include reprimand by the appropriate supervisor, dismissal, criminal prosecution or any
other sanction as outlined in the college’s Policies and Procedures Manual.
2. Students -- A student found guilty of misuse of the network is subject to loss of network
privileges, criminal prosecution, or any other disciplinary action described in the MDCC
Catalog.
3. Public -- A member of the public found guilty of misuse of the network is subject to loss
of network privileges and/or criminal prosecution.
SAMPLE FOR YOUR FILES—DO NOT SIGN!
MISSISSIPPI DELTA COMMUNITY COLLEGE
INFORMATION NETWORK RESOURCES EMPLOYEE USE AGREEMENT
I hereby agree to use professional judgment with regard to use of the college network resources. Specifically, I will
not:
1. use the college network or any device connected to the college network for any purpose other than official
college business. I will not use the network for illegal purposes, profit-making activities, political activities,
or to harass anyone or any organization.
2. access sites which contain pornography and other sexually explicit material.
3. reveal my system password to anyone, or make it possible for anyone to access it by posting it or by
the careless handling of it.
4. access, view, alter or attempt to access, view or alter college information except that which is permitted
by my password, and only then in the performance of my job.
5. allow or assist any unauthorized individual to access, view or alter college information, or share such
information with them except as authorized by appropriate authority.
6. connect any electronic device to, remove any electronic device from, or alter any electronic device which is
connected to the college network without the expressed permission of the Director of Information
Technology.
7. relocate or disturb any of the network infrastructure (including wiring, hubs, switches, connectors, etc.)
without the expressed permission of the Director of Information Technology.
8. move a college network device (microcomputer, printer, etc.) from its assigned location without notifying
Computer & Information Services and completing an Inventory Deletion/Relocation Form obtained from the
Business Office.
9. share knowledge of the college network infrastructure with anyone except an authorized college employee.
10. load any file which has not been scanned for viruses to a networked computer.
11. install any software on a computer without the approval of the Director of Information Technology,
and will not duplicate copyrighted or licensed software or other materials unless specifically
permitted to do so by author or publisher agreement.
12. store on college media (disks, tape, etc.) any materials which violate sexual harassment or civil rights
policy.
I
understand my responsibility with respect to ensuring appropriate security, confidentiality, and use of the
college network. I also understand that the college is not responsible for any consequences or legal actions that
may result because of my misuse of the college network resources. I have read and do understand the above
conditions. I realize that failure to comply with any of the above conditions can result in disciplinary action
against me as described in the college's Policies and Procedures Manual.
Signed
SAMPLE ONLY—DO NOT SIGN!
Date
MISSISSIPPI DELTA COMMUNITY
COLLEGE
INFORMATION
NETWORK
RESOURCES
EMPLOYEE USE
AGREEMENT
I hereby agree to use professional judgment with regard to use of the college network resources. Specifically, I will
not:
1. use the college network or any device connected to the college network for any purpose other than official
college business. I will not use the network for illegal purposes, profit-making activities, political activities,
or to harass anyone or any organization.
2. access sites which contain pornography and other sexually explicit material.
3. reveal my system password to anyone, or make it possible for anyone to access it by posting it or by
the careless handling of it.
4. access, view, alter or attempt to access, view or alter college information except that which is permitted
by my password, and only then in the performance of my job.
5. allow or assist any unauthorized individual to access, view or alter college information, or share such
information with them except as authorized by appropriate authority.
6. connect any electronic device to, remove any electronic device from, or alter any electronic device which is
connected to the college network without the expressed permission of the Director of Information
Technology.
7. relocate or disturb any of the network infrastructure (including wiring, hubs, switches, connectors, etc.)
without the expressed permission of the Director of Information Technology.
8. move a college network device (microcomputer, printer, etc.) from its assigned location without notifying
Computer & Information Services and completing an Inventory Deletion/Relocation Form obtained from the
Business Office.
9. share knowledge of the college network infrastructure with anyone except an authorized college employee.
10. load any file which has not been scanned for viruses to a networked computer.
11. install any software on a computer without the approval of the Director of Information Technology,
and will not duplicate copyrighted or licensed software or other materials unless specifically
permitted to do so by author or publisher agreement.
12. store on college media (disks, tape, etc.) any materials which violate sexual harassment or civil rights
policy.
I
understand my responsibility with respect to ensuring appropriate security, confidentiality, and use of the
college network. I also understand that the college is not responsible for any consequences or legal actions that
may result because of my misuse of the college network resources. I have read and do understand the above
conditions. I realize that failure to comply with any of the above conditions can result in disciplinary action
against me as described in the college's Policies and Procedures Manual.
Signed
Date
Print
Name
MISSISSIPPI DELTA COMMUNITY COLLEGE
INFORMATION NETWORK RESOURCES STUDENT / PATRON USE AGREEMENT
I hereby agree to the following conditions with regard to use of the college network resources. Specifically, I will
not:
1. use the college network or any device connected to the college network for any purpose other than course
related assignments and research. I will not use the network for illegal purposes, profit-making activities,
political activities, or to harass anyone or any organization.
2. access sites which contain pornography and other sexually explicit material.
3. reveal my system password to anyone, or make it possible for anyone to access it by posting it or by
the careless handling of it.
4. access, view, alter or attempt to access, view or alter college information except that which is permitted
by my password.
5. allow or assist any unauthorized individual to access, view or alter college information, or share such
information with them.
6. use a modem in a college networked computer to connect to any external site (for example, the Internet or
an off-campus computer).
7. connect any electronic device to, remove any electronic device from, or alter any electronic device which is
connected to the college network.
8. relocate or disturb any of the network infrastructure (including wiring, hubs, switches, connectors, etc.).
9. move a college network device (microcomputer, printer, etc.) from its assigned location.
10. load any file which has not been scanned for viruses to a networked computer.
11. install any software on a computer, and will not duplicate copyrighted or licensed software or other
materials unless specifically permitted to do so by author or publisher agreement.
12. store on college media (disks, tape, etc.) any materials which violate sexual harassment or civil rights policy.
13. access Internet e-mail using network computers not designated for that purpose.
I understand my responsibility with respect to ensuring appropriate security, confidentiality, and use of the
college network. I also understand that the college is not responsible for any consequences or legal actions
that may result because of my misuse of the college network resources. I have read and do understand the
above conditions. I realize that failure to comply with any of the above conditions can result in disciplinary
action against me as described in the college's Student Handbook.
Signed
Date
Print
Name
SAMPLE FOR YOUR FILES—DO NOT SIGN!
MISSISSIPPI DELTA COMMUNITY COLLEGE
INFORMATION NETWORK RESOURCES STUDENT / PATRON USE AGREEMENT
I hereby agree to the following conditions with regard to use of the college network resources. Specifically, I will
not:
1. use the college network or any device connected to the college network for any purpose other than course
related assignments and research. I will not use the network for illegal purposes, profit-making activities,
political activities, or to harass anyone or any organization.
2. access sites which contain pornography and other sexually explicit material.
3. reveal my system password to anyone, or make it possible for anyone to access it by posting it or by
the careless handling of it.
4. access, view, alter or attempt to access, view or alter college information except that which is permitted
by my password.
5. allow or assist any unauthorized individual to access, view or alter college information, or share such
information with them.
6. use a modem in a college networked computer to connect to any external site (for example, the Internet or
an off-campus computer).
7. connect any electronic device to, remove any electronic device from, or alter any electronic device which is
connected to the college network.
8. relocate or disturb any of the network infrastructure (including wiring, hubs, switches, connectors, etc.).
9. move a college network device (microcomputer, printer, etc.) from its assigned location.
10. load any file which has not been scanned for viruses to a networked computer.
11. install any software on a computer, and will not duplicate copyrighted or licensed software or other
materials unless specifically permitted to do so by author or publisher agreement.
12. store on college media (disks, tape, etc.) any materials which violate sexual harassment or civil rights policy.
13. access Internet e-mail using network computers not designated for that purpose.
I understand my responsibility with respect to ensuring appropriate security, confidentiality, and use of the
college network. I also understand that the college is not responsible for any consequences or legal actions
that may result because of my misuse of the college network resources. I have read and do understand the
above conditions. I realize that failure to comply with any of the above conditions can result in disciplinary
action against me as described in the college's Student Handbook.
Signed
SAMPLE ONLY—DO NOT SIGN!
Date
MISSISSIPPI DELTA COMMUNITY COLLEGE
Office of Information Technology
it@msdelta.edu
662.246.6330
Fax:
662.246.6431
USER ACCESS REQUEST FOR
M
This request must be preceded by the signed and dated Information Network Resources Use
Agreement.
D
a
te:
Please clearly print the following information---
Full N
ame
:
Preferred First Name: __________________________________________
La
st
4 di
g
i
ts
of
Soc
ial
Sec
uri
ty
#:
D
a
te
o
f
Bi
r
th:
Tit
l
e:
Full-time Part-time
De
partm
e
n
t:
For Office of Information Technology use only
Received Signed Employee Use Agreement? Yes No
Employee ID #: _________________ User Name: _____________________________
Email Address: ___________________________________________________________
Setup Active Directory/Network account – Done by: __________________________
Setup Email account – Done by: ___________________________________________
Notified Supervisor of Employee – Done by: _________________________________
Sent Welcome Email – Done by: ___________________________________________
Sent FERPA Email – Done by: ______________________________________________
Sent Policies & Procedures Email – Done by: __________________________________
MISSISSIPPI DELTA COMMUNITY COLLEGE
Assigning Registration Time Tickets in MyBanner (SSB)
1. Log in to the MyDelta Portal.
2. Click the MyBanner link.
3. Click on Faculty and Advisors menu item OR the Faculty Services tab.
4. Scroll to the bottom of the page and click on Registration Time Ticket.
5. If a term has not been previously selected, click on the down arrow to select the term then click
6. Submit.
7. If a student has not been previously selected, select a student ID by either entering the
student’s Banner ID OR entering the student’s last name, first name and then click Submit.
8.
If searching for a student by name, click on the down arrow next to the name then click on
9. the name from the list (NOTE: DO NOT JUST SELECT THE FIRST NAME DISPLAYED - it may not be
the student you are searching for).
10. After the student name has been selected, verify the information, and then click Submit.
11. Click on Registration Time Ticket again and the students ID, name and major will display.
12. To assign a time ticket, click on the down arrow next to Select Group.
13. Click on the group based on the major or other instructions you received on assigning time
ticket groups for this term.
14. Click on Assign this Group.
15. Verify that the correct group was assigned to this student.
16. To change the time ticket group click on down arrow next to Select Group, select the new
group, click on Submit.
17. To remove a student from a group so they will not be able to register in SSB, click on Remove
18. Time Ticket Group at the top of the screen.
19. 17. To proceed with another student click Student ID Selection in brackets at the bottom of
the screen and repeat the steps for selecting a student and assigning a group as listed
above
20.
18. When finished click on Exit at top of screen.
ATTENDANCE MODULE INTEGRATED WITH BANNER
Page
1
MISSISSIPPI DELTA COMMUNITY COLLEGE
ATTENDANCE MODULE INTEGRATED WITH BANNER
Please review the following detailed explanation of the Attendance roll integration with Banner.
•
LDA = Last Date of Attendance
•
When a student registers for a class on the web (SSB/MyBanner), "RW" status code is assigned. When a
student is registered directly in Banner (INB) for a class, "RE" status code is assigned. These codes are
displayed on the Attendance roll under the Reg column. When a student is dropped from a class the status
code will be changed as follows:
The registration status code for any student marked as a no show will be changed to "DD" and the first
day of class is used as the status date. Any student marked as Cls WD whose LDA is within the refund
period (two weeks) will also be changed to "DD". The student will be removed from the Detail and
Summary Class List in SSB/MyBanner but will remain on the Attendance roll. The student will receive a
100% refund for the class.
After the refund period, the registration status code for a student marked as Cls WD will be changed to
"DC" and the LDA (last date of attendance) will be used as the status date. A "W" grade will be
automatically assigned. The student will not receive a refund for the class.
The registration status code for a student marked as Exc Abs will also be changed to "DC" and the LDA
will be used as the status date. An "F" grade will automatically be assigned, but may be changed to
"W" using the Final Grade option on the Faculty Services tab in SSB/MyBanner using established.
If a student is readmitted (reinstated) to a class, the "DC" status code will be changed back to "RE".
The LDA and grade will also be removed.
If a student is withdrawn from school (ALL classes) in Banner, "WS" enrollment status code is assigned
to the student term record in Banner. If all classes have been recorded as no shows or dropped within
the refund period "WD" is assigned to the student term record.
•
Currently VCC class withdrawals are processed directly in Banner (INB).
•
ATTENDANCE REMINDERS:
All attendance (absences, class withdrawals, no shows) should be up-to-date and complete prior to
entering final grades!
Please do not wait to assign a W grade at grade entry time! If a student has “cut out” or withdrawn,
you should go through the proper steps in the attendance module to record that prior to grade entry
time! If you do give a W grade at grade entry time, you MUST enter an LDA!
When finished with marking absences for the class, be sure to click on Save Audit Roll or you will lose
attendance entered. *NOTE: You MUST save attendance before changing weeks. For example, if
you enter attendance for Weeks 1-4, and want to then record attendance for Weeks 5-8, you must
save Weeks 1-4 before proceeding to the Weeks 5-8 screen.
•
The information in the Attendance roll will be updated in Banner each afternoon (5:00 pm).
•
The information for a dropped class will only be updated in Banner once. If LDA has been entered incorrectly,
the Final Grade option on the Faculty Services tab may be used to make a correction. A correct LDA
is
e
ss
e
ntial
for financial aid and state board auditing purposes.
Contact The Office of Information Technology if you have technical issues.
******************************************************************************************
ATTENDANCE MODULE INTEGRATED WITH BANNER
Page
2
Recording Attendance
•
Click on MyBanner link from the MDCC web site at www.msdelta.edu
•
Click on MyBanner Log In.
•
Click on Enter Secure Area on the initial Self Service Banner (SSB/MyBanner) page.
•
Enter your User ID (Banner ID or SSN) and your PIN (Password).
•
Click on Log In.
•
Click on Faculty and Advisors menu item OR the Faculty Services tab.
•
Scroll to the bottom of the page and click on Attendance Roll Form.
•
Click on the down arrow next to the Class(es) heading, then click on a class to enter attendance.
•
Click on the Week in the semester for which attendance is to be entered (Weeks 1-4, 5-8, etc.), if not already
selected.
•
To mark a student absent, click on the box under the correct class meeting (NOTE: hovering over box will
display date).
•
After clicking once an "A” will be inserted in the box.
•
To remove an absence, click on "A" and it will be removed.
•
If the box is blank, it is assumed that the student was present.
•
Continue marking students absent.
•
IMPORTANT! When finished with marking absences for the class, be sure to click on Save Audit Roll or you
will lose attendance entered. *NOTE: You MUST save attendance before changing weeks. For example, if you
enter attendance for Weeks 1-4, and want to then record attendance for Weeks 5-8, you must save Weeks 1-4
before proceeding to the Weeks 5-8 screen.
•
Your initials and date of birth will be automatically saved in the database indicating you certify the attendance
entered.
Recording No Shows
•
When instructed to record no shows for the semester, click on the down arrow under the Status column for
the student.
•
Click on No Show.
•
Boxes will be grayed out and will be automatically marked as absences for the remainder of the semester
when saved.
•
When finished marking no shows click on Save Audit Roll.
•
When transferred to Banner, the Reg status will be changed to "DD" and the first day of class is used as the
status date. The student will be removed from the Detail and Summary Class List in Banner but will remain on
the Attendance roll. The student will receive a 100% refund for the class.
ATTENDANCE MODULE INTEGRATED WITH BANNER
Page
3
Recording Class withdrawals
•
Click on the down arrow under the Status column for the student.
•
To officially withdraw a student from class, click on the Cls WD in the list.
•
Click on the down arrow next to the date box under Cls WD, and select the LDA from the list.
•
Boxes after the LDA will be grayed out and will be automatically marked as absences for the remainder of the
semester when saved.
•
When finished, click on Save Audit Roll.
•
When transferred to Banner and the LDA is after the refund period, the Reg status will be changed to "DC" and
the LDA will be used as the status date. A "W" grade will be automatically assigned. The students will not
receive a refund.
•
If the LDA is within the refund period, "DD" will be assigned. The student will be removed from the Detail and
Summary Class List in Banner but will remain on the Attendance roll. The student will receive a 100% refund
for the class.
Recording Excessive Absences (Cut Outs)
•
Click on the down arrow under the Status column for the student.
•
To officially withdraw a student from class due to excessive absences, click on Exc Abs in the list.
•
Click on the down arrow next to the date box under Exc Abs, and select the LDA from the list.
•
Boxes after the LDA will be grayed out and will be automatically marked as absences for the remainder of the
semester when saved.
•
When finished click on Save Audit Roll.
•
When transferred to Banner and the LDA is after the refund period, the Reg status will be changed to "DC" and
the LDA will be used as the status date. An "F" grade will automatically be assigned, but may be changed to
"W" on the Final Grade option under the Faculty Services tab using established grading policies.
•
If the LDA is within the refund period, "DD" will be assigned. The student will be removed from the Detail and
Summary Class List in Banner, but will remain on the Attendance roll. The student will receive a 100% refund
for the class.
Readmitting (Reinstate) a student
•
Click on the down arrow under the Status column for the student to be readmitted to class.
•
Click on Readmit.
•
Students LDA will be removed and all absences will be retained.
•
Click on absences from date readmitted to end of semester (through Week 17 - 18) to remove absences.
•
When finished, click on Save Audit Roll.
•
When transferred to Banner, the Reg status will be changed back to "RE”. The LDA and "W" grade will also be
removed.
Banner – Final Grade Entry
Page
1
MISSISSIPPI DELTA COMMUNITY COLLEGE
BANNER – Final Grade
Entry
*MDCC does not record mid-term
g
r
ad
es*
•
IMPORTANT! All attendance records should be updated before proceeding with final grades!
**Please do not wait to assign a W grade at grade entry time! If a student has “cut out” or withdrawn, you
should go through the proper steps in the attendance module to record that prior to grade entry time!
•
Click on MyBanner link from the MDCC web site at www.msdelta.edu
•
Click on MyBanner Log In.
•
Click on Enter Secure Area on the initial Self Service Banner (SSB/MyBanner) page.
•
Enter your User ID (Banner ID or SSN) and your PIN (Password).
•
Click on Log In.
•
Click on Faculty and Advisors menu item OR the Faculty Services tab.
•
Click on Final Grades.
•
If a term has not been previously selected, click on the down arrow to select the term then click Submit.
•
Click on the down arrow to select the CRN for class, and then click Submit.
•
Click on the down arrow under the grade column and select a grade.
**NOTE: For class withdrawals leave the grade as "W". For excessive absences the grade may be left
as "F" or changed to "W" based on school policy.
**NOTE: Instructors cannot enter an “I” grade in MyBanner. If you need to assign an “I” grade,
please contact the Office of Instruction at 662.246.6317. If an “I” grade for incomplete is assigned,
please remember that according to college policy, the “I” grade will be changed to “F” within one year
if you do not submit a change of grade form to the Office of Admissions before the incomplete
extension date.
•
Last Attend Date should be blank for students completing the class. If a student has a class withdrawal or
excessive absences, check the last attend date and correct if necessary. The date should be entered in
MM/DD/YYYY format (include the slashes).
**NOTE: Students that show “non-gradable” in the final grade column should NOT have a date in the
LDA field. If there is a date in that field, grades for other students will not post.
**NOTE: If you give a "W" grade, a LDA MUST be entered. Also, if an “F” grade was assigned to a cut-
out, a LDA MUST be entered. An EARNED “F” grade should NOT have an LDA.
Also – there seems to be some confusion about this -- “Last Attend Date should be blank for students
completing the class with a grade.” You only enter an LDA if the student cut out or withdrew from the
class. The date should be entered in MM/DD/YYYY format (include the slashes).” To explain – According
to policy, at some point in the semester, you have the option to give a student a W or F grade if a student
cuts out or withdraws from your class. If you decide to give an F grade, you still must put an LDA because
the student either cut out or withdrew & did not complete the class. The key word in the statement
above is “completing”. If a student cuts out or withdraws from your class, this is not considered
completing the course with a grade, although you may choose to give an F grade.
Banner – Final Grade Entry
Page
2
ALL CUT OUTS & CLASS WITHDRAWALS MUST HAVE EITHER A W OR F GRADE AND MUST HAVE AN LDA!
•
Leave Attend Hours blank.
•
A reminder message will display at the bottom of the page that you have 20 minutes to finish entering grades
for this class.
•
When finished entering all grades, click Submit. A message will be displayed at the top of the screen
indicating the changes were successfully saved or error messages will inform you of any errors.
•
If the Rolled column contains an N you may update the grade. When all grades for the term have been
received, they will be rolled (updated) in history and any grade changes will need to be made by the
Admissions office.
•
To enter grades for another class click on CRN selection at the bottom of the screen, select the CRN for the
class, select Final Grades, and then repeat steps above.
•
Verify that all grades have been entered correctly.
•
Click on Exit when finished.
Mississippi Delta Community Co
ll
ege
Frequently Asked Questions
Employees and students must know how to log on to the MyDelta portal, Email, MyBanner, and
Canvas (students & faculty) and should be checking them frequently.
Detailed instructions for use of MyDelta Portal, etc. can be found on the Office of Information
Technology section of the MDCC website -- http://www.msdelta.edu/information-technology/
Student problems or questions related to admission status, grades, or transcripts?
➢ Contact the Office of Admissions & Records at 662.246.6306 or email
admissions@msdelta.edu
Student problems or questions about Financial Aid?
➢ Contact the Office of Financial Aid at 662.246.6263 or 662.246.6310
Student problems or questions about student accounts, financial aid refunds?
➢ Contact the Office of Business Services at 662.246.6312.
Student or Employee problems or questions concerning online classes or Canvas?
➢ Contact the Office of eLearning at 662.246.6319 or email vccdlc@msdelta.edu
Student or Employee problems or questions concerning MyDelta Portal, Banner, Argos,
MyBanner or Email?
➢ Contact Office of Information Technology at 662.246.6330 or by emailing it@msdelta.edu
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