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
MS Delta Community College
Hwy. 3 & Cherry Street - P. O. Box 668
Moorhead
MS
38761
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
2021
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 estimator at www.irs.gov/W4App, 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 2021 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 total 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 (2021)
click to sign
signature
click to edit
Form W-4 (2021)
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, Tax Withholding and Estimated Tax.
Exemption from withholding. You may claim exemption
from withholding for 2021 if you meet both of the following
conditions: you had no federal income tax liability in 2020
and you expect to have no federal income tax liability in
2021. You had no federal income tax liability in 2020 if (1)
your total tax on line 24 on your 2020 Form 1040 or 1040-SR
is zero (or less than the sum of lines 27, 28, 29, and 30), 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 2021 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 15, 2022.
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 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. This step 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 2021 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 (2021)
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 2021 itemized deductions (from Schedule A (Form 1040)). 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:
{
• $25,100 if you’re married filing jointly or qualifying widow(er)
• $18,800 if you’re head of household
• $12,550 if you’re single or married filing separately
}
........ 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. 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)). 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 (2021)
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 $190 $850 $890 $1,020 $1,020 $1,020 $1,020 $1,020 $1,100 $1,870 $1,870
$10,000 - 19,999
190 1,190 1,890 2,090 2,220 2,220 2,220 2,220 2,300 3,300 4,070 4,070
$20,000 - 29,999 850 1,890 2,750 2,950 3,080 3,080 3,080 3,160 4,160 5,160 5,930 5,930
$30,000 - 39,999
890 2,090 2,950 3,150 3,280 3,280 3,360 4,360 5,360 6,360 7,130 7,130
$40,000 - 49,999
1,020 2,220 3,080 3,280 3,410 3,490 4,490 5,490 6,490 7,490 8,260 8,260
$50,000 - 59,999 1,020 2,220 3,080 3,280 3,490 4,490 5,490 6,490 7,490 8,490 9,260 9,260
$60,000 - 69,999
1,020 2,220 3,080 3,360 4,490 5,490 6,490 7,490 8,490 9,490 10,260 10,260
$70,000 - 79,999
1,020 2,220 3,160 4,360 5,490 6,490 7,490 8,490 9,490 10,490 11,260 11,260
$80,000 - 99,999 1,020 3,150 5,010 6,210 7,340 8,340 9,340 10,340 11,340 12,340 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,930 7,130 8,260 9,320 10,520 11,720 12,920 14,120 15,090 15,290
$150,000 - 239,999
2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,230 16,190 16,400
$240,000 - 259,999 2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,270 17,040 18,040
$260,000 - 279,999
2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,870 14,870 16,870 18,640 19,640
$280,000 - 299,999
2,040 4,440 6,500 7,900 9,230 10,470 12,470 14,470 16,470 18,470 20,240 21,240
$300,000 - 319,999 2,040 4,440 6,500 7,940 10,070 12,070 14,070 16,070 18,070 20,070 21,840 22,840
$320,000 - 364,999
2,720 5,920 8,780 10,980 13,110 15,110 17,110 19,110 21,190 23,490 25,560 26,860
$365,000 - 524,999
2,970 6,470 9,630 12,130 14,560 16,860 19,160 21,460 23,760 26,060 28,130 29,430
$525,000 and over
3,140 6,840 10,200 12,900 15,530 18,030 20,530 23,030 25,530 28,030 30,300 31,800
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 $440 $940 $1,020 $1,020 $1,410 $1,870 $1,870 $1,870 $1,870 $2,030 $2,040 $2,040
$10,000 - 19,999
940 1,540 1,620 2,020 3,020 3,470 3,470 3,470 3,640 3,840 3,840 3,840
$20,000 - 29,999 1,020 1,620 2,100 3,100 4,100 4,550 4,550 4,720 4,920 5,120 5,120 5,120
$30,000 - 39,999
1,020 2,020 3,100 4,100 5,100 5,550 5,720 5,920 6,120 6,320 6,320 6,320
$40,000 - 59,999
1,870 3,470 4,550 5,550 6,690 7,340 7,540 7,740 7,940 8,140 8,150 8,150
$60,000 - 79,999 1,870 3,470 4,690 5,890 7,090 7,740 7,940 8,140 8,340 8,540 9,190 9,990
$80,000 - 99,999
2,000 3,810 5,090 6,290 7,490 8,140 8,340 8,540 9,390 10,390 11,190 11,990
$100,000 - 124,999
2,040 3,840 5,120 6,320 7,520 8,360 9,360 10,360 11,360 12,360 13,410 14,510
$125,000 - 149,999 2,040 3,840 5,120 6,910 8,910 10,360 11,360 12,450 13,750 15,050 16,160 17,260
$150,000 - 174,999
2,220 4,830 6,910 8,910 10,910 12,600 13,900 15,200 16,500 17,800 18,910 20,010
$175,000 - 199,999
2,720 5,320 7,490 9,790 12,090 13,850 15,150 16,450 17,750 19,050 20,150 21,250
$200,000 - 249,999 2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$250,000 - 399,999
2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$400,000 - 449,999
2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,910 21,220 22,520
$450,000 and over
3,140 6,250 8,830 11,330 13,830 15,790 17,290 18,790 20,290 21,790 23,100 24,400
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 $820 $930 $1,020 $1,020 $1,020 $1,420 $1,870 $1,870 $1,910 $2,040 $2,040
$10,000 - 19,999
820 1,900 2,130 2,220 2,220 2,620 3,620 4,070 4,110 4,310 4,440 4,440
$20,000 - 29,999 930 2,130 2,360 2,450 2,850 3,850 4,850 5,340 5,540 5,740 5,870 5,870
$30,000 - 39,999
1,020 2,220 2,450 2,940 3,940 4,940 5,980 6,630 6,830 7,030 7,160 7,160
$40,000 - 59,999
1,020 2,470 3,700 4,790 5,800 7,000 8,200 8,850 9,050 9,250 9,380 9,380
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,850 11,050 11,250 11,520 12,320
$80,000 - 99,999
1,880 4,280 5,710 7,000 8,200 9,400 10,600 11,250 11,590 12,590 13,520 14,320
$100,000 - 124,999
2,040 4,440 5,870 7,160 8,360 9,560 11,240 12,690 13,690 14,690 15,670 16,770
$125,000 - 149,999 2,040 4,440 5,870 7,240 9,240 11,240 13,240 14,690 15,890 17,190 18,420 19,520
$150,000 - 174,999
2,040 4,920 7,150 9,240 11,240 13,290 15,590 17,340 18,640 19,940 21,170 22,270
$175,000 - 199,999
2,720 5,920 8,150 10,440 12,740 15,040 17,340 19,090 20,390 21,690 22,920 24,020
$200,000 - 249,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$250,000 - 349,999
2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$350,000 - 449,999
2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,900 25,200
$450,000 and over 3,140 6,840 9,570 12,160 14,660 17,160 19,660 21,610 23,110 24,610 26,050 27,350
)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
f
or 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: _______________________
______ Ph
one: ___________________________
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: ________________________________________________________________________
_________________________________________________________________________________________
*C
ity: ___________________________ *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
Bu
siness Office
P.
O. Box 668
Moorh
ead
MS
38
761
06
68
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
EMPLOYEE ACKNOWLEDGEMENT
Mississippi Delta Community College provides qualified, competent administrators, faculty, and staff
members who are committed to fulfilling the goals of the institution.
Definitions:
• “Contractual” employee – a full-time administrator, faculty, or staff member who is under written
contract. A written contract establishes the terms and conditions of employment.
• An “at will” employee (non-contractual full time or part time) serves “at will” of the President.
This means that either the college or the employee may terminate the employment relationship at
any time, with or without notice and with or without cause.
Probation:
All faculty and staff members are considered to be hired for a probationary period for the first
employment period. Probation also applies when an employee takes a new position. During the course
of the probationary period, the employee's performance will be evaluated by his/her supervisor(s); and
the appropriate administrator will recommend to the President whether or not a faculty/staff member's
employment should be renewed or discontinued.
• Non-contractual employee’s probationary period is one year from his or her effective
date of employment.
• Contractual employee’s probationary period is anywhere between 9 months to 12 months.
________________________________________ ________________________________________
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
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
Membership Application
Form 1 – Revised 07/01/2016
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Member Information – Attach a copy of the member’s Social Security card.
First Name: _______________________________________ MI: ______ Last Name: ______________________________________ Gender: M F
Provide previous name, if applicable. First Name: _______________________________ MI: _____ Last Name: __________________________________
Social Security No.: ______________________ Birth Date mm/dd/ccyy: ____________________ E-Mail: ________________________________________
Mailing Address: _____________________________________________________________ City: ______________________ State: _____ Zip: ________
Phone: _______________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Have you previously served on active duty in the U.S. Armed Forces? If yes, attach Form(s) DD214 ........................................................... Yes No
Have you ever been a member of the Optional Retirement Plan (ORP) for Institutions of Higher Learning in the State of Mississippi? ................. Yes No
Retirement Plan – Plans are governmental defined benefit plans qualified under Section 401(a) of the Internal Revenue Code. Select applicable plan.
Public Employees’ Retirement System of Mississippi (PERS) Mississippi Highway Safety Patrol Retirement System (MHSPRS)
Supplemental Legislative Retirement Plan (SLRP)
Family Information – Use additional Membership Applications if listing more than four dependent children. Information is for determining statutory
benefits only. Use Form 1B, Beneficiary Designation, to officially designate any and all beneficiaries.
Marital Status – Select one. Add date for last three. Single Married Divorced Widowed Effective Date mm/dd/ccyy: ________________
Spouse’s Full Name Social Security No. Birth Date mm/dd/ccyy Wedding Date mm/dd/ccyy Gender
_____________________________________ ____________________________ _______________________ _______________________ M F
Dependent Child’s Full Name – Up to age Social Security No. Birth Date mm/dd/ccyy Relationship Gender
19, or 23 if unmarried and a full-time student
_____________________________________ ____________________________ _______________________ _______________________ M F
_____________________________________ ____________________________ _______________________ _______________________ M F
_____________________________________ ____________________________ _______________________ _______________________ M F
_____________________________________ ____________________________ _______________________ _______________________ M F
Member Certification – 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.
Member’s Signature: ______________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification – This section must be completed by an authorized employer representative, not the member.
Member’s Position Held/Job Title: _____________________________________________ Member’s Hire Date mm/dd/ccyy: _____________________
Member’s Status: Elected Official: Yes No Fee Paid Official: Yes No Public Safety Employee: Yes No
Employer Name: ____________________________________________________________ Employer No.: __________________ - _________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: __________________________ E-Mail: __________________________________
As employer representative, I certify that employment in this position meets 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: _____________________
Mississippi Delta Community College
0
620
0
00
Sarah Hanson
Personnel Coordinator
(662) 246-6313
(662) 246-6324
shanson@msdelta.
edu
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
Beneficiary Designation
Form 1B – Revised 07/01/2016
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Member/Retiree Information
Fi
rst Name: _______________________________________ MI: ______ Last Name: ___________________________________ Member Retiree
Social Security No.: ____________________________ Birth Date mm/dd/ccyy: ____________________________________________ Gender: M F
Retirement Plan – Plans are governmental defined benefit plans qualified under Section 401(a) of the Internal Revenue Code. Select applicable plan.
Public Employees’ Retirement System of Mississippi (PERS) Mississippi Highway Safety Patrol Retirement System (MHSPRS)
Supplemental Legislative Retirement Plan (SLRP)
Beneficiary Information – Use additional Form 1B, Beneficiary Designation, to designate additional beneficiaries. If more than one primary beneficiary
is named, the primary beneficiaries shall share equally unless otherwise indicated. Likewise, if more than one secondary beneficiary is named, the secondary
beneficiaries shall share equally unless otherwise indicated. Total primary and secondary beneficiary percentages must equal 100 percent.
Beneficiary Name Social Security No. Birth Date Relationship Beneficiary Percentage Gender
mm/dd/ccyy P=Primary, S=Secondary
Use whole numbers
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
_____________________________________ ________________________ ____________ _________________ P S ________ % M F
Member/Retiree Certification – Check applicable acknowledgement then sign. 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.
M
ember – I acknowledge and understand that the PERS Board of Trustees is authorized to pay benefits in accordance with the statutory provisions
that govern the retirement system in which I am a member. To the extent permitted by such statutory provisions at the time of my death prior t
o
r
etirement, I hereby designate the above beneficiary(ies) to receive the payment of my accumulated contributions and any interest relating thereto. I
further acknowledge and understand that certain benefits may be required by law to be paid that may limit, partially or totally, any payment to my
d
esignated beneficiary(ies).
Retiree – I hereby designate the above beneficiary(ies) to receive any residual amount payable by reason of my death and the death of my joint
annuitant(s), if applicable.
Member/Retiree’s Signature: ________________________________________________________________ Date mm/dd/ccyy:______________________
Employer Certification – This section must be completed by an authorized employer representative, not the member. Only complete for active members.
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
0
620
0
00
Sarah Hanson Personnel Coordinator
(662) 246-6313 (662) 246-6324 shanson@msdelta.edu
Application for Coverage Mississippi State and School Employees’ Health Insurance Plan Health1 (1/17)
STATE OF MISSISSIPPI
STATE AND SCHOOL EMPLOYEES’ HEALTH INSURANCE PLAN
APPLICATION FOR COVERAGE
PLEASE PRINT
Section A: Enrollee Information (all fields are required)
Social Security Number
First Name
MI
Last Name
Home Address
City
State
ZIP
Primary Telephone Number
Secondary Telephone Number
Personal Email Address
Marital Status
Single Married
Gender
Male Female
Date of Birth (mm/dd/yyyy)
Date of Employment/Retirement
Were you ever a full-time employee of a covered entity under the Plan prior to 1/1/2006? No (Horizon) Yes (Legacy)
If yes, please list your most recent (pre-1/1/06) employer and dates of employment: ________________________________________________________
_________________________________________________________________________________________________________________________________________
If married, is your spouse a Plan participant? Yes No If yes, Spouse Name and SSN: ________________________________________________
Section B: Health Insurance Membership Agreement Authorization (CHECK ONLY ONE BOX, SIGN AND DATE)
I hereby apply to ADD, CONTINUE AND/OR CHANGE COVERAGE for myself and/or my dependents named on this Application For
Coverage form through the State and School Employees' Health Insurance Plan (PLAN). I certify that all information provided by me on this
application is complete and accurate, and is the basis for providing coverage herein. I understand that any misrepresentation by me or my
dependents may result in the cancellation of my/our coverage under the PLAN. I understand that the coverage applied for is subject to all
exclusions, provisions, and limitations set forth by the Plan Document. I agree to be bound by all terms and conditions of the PLAN. I understand
and agree that if my application for coverage is approved, any requested coverage changes will be effective the date fixed by the PLAN or
its Administrator. I understand that if the requested coverage is approved, I am responsible for payment of the appropriate premiums and
hereby authorize for such payments to be payroll deducted, or as appropriate, withheld from my State of Mississippi retirement benefits.
I hereby WAIVE COVERAGE in the State and School Employees’ Health Insurance Plan. I have been offered coverage (or am eligible for
continuation of coverage) through the PLAN, but I elect not to be covered. I understand that by waiving coverage at this time, I may only
request coverage for myself or myself and eligible dependents at an Open Enrollment Period or during a Special Enrollment Period. I understand
that if I am a retiree and I waive coverage, I will not be allowed to re-enroll or have my coverage reinstated at a later date. If you are waiving
coverage because you are currently covered under another health insurance policy, please complete Section D.
Enrollee Signature: _________________________________________________________ Date: ______________________________________
Section C: Coverage
Enrollee Type:
Employee - Legacy
Employee - Horizon
Retiree
COBRA
Surviving Spouse
Coverage Type:
Enrollee Only
Enrollee + Spouse
Enrollee + Child
Enrollee + Children
Enrollee + Spouse & Child(ren)
Coverage Option:
(Choose Only One)
Select
Base (HIGH DEDUCTIBLE)
Do you have Medicare? Yes No
Medicare Number: ___________________________
“A
” Effective Date: _________________________
“B” Effective Date: _________________________
Reason for Entitlement:
Age ESRD Disability
Are you a tobacco user? Yes No If yes, are you interested in participating in the Plan’s free cessation program? Yes No
Section D: Other Coverage Information
Do any of the persons listed on this application have other health insurance coverage? Yes No
If yes, please provide the following:
Name of Individual Covered: 1.____________________ 2.____________________ 3.______________________ 4.___________________
Policyholder’s Name: _______________________ __________________________ __________________________ _______________________
Policyholder’s Date of Birth: _______________________ __________________________ __________________________ _______________________
Policyholder’s Insurance
Effective Date: _______________________ __________________________ __________________________ _______________________
Policy Number: _______________________ __________________________ __________________________ _______________________
Policyholder’s Employment
Status:
Insurance Company Name _______________________ __________________________ __________________________ _______________________
address & phone #: _______________________ __________________________ __________________________ _______________________
_______________________ __________________________ __________________________ _______________________
_______________________ __________________________ __________________________ _______________________
Coverage Type:
Employer Name
Active, Retiree or COBRA
Active, Retiree or COBRA Active, Retiree or COBRA Active, Retiree or COBRA
Group Non-Group Group Non-Group Group Non-Group Group Non-Group
Application for Coverage Mississippi State and School Employees’ Health Insurance Plan Health1 (1/17)
Enrollee Last Name:
First Name:
Enrollee SSN:
Section E: Dependents
Dependents to be Covered
(Last Name, First Name, MI)
Relation to
Enrollee
Social Security
Number
Date of Birth
(mm/dd/yyyy)
Address
(if different from Enrollee)
Current Status
1.
Spouse
Male
Female
Employed
?
2.
Son
Daughter
Child under 26
Disabled
3.
Son
Daughter
Child under 26
Disabled
4.
Son
Daughter
Child under 26
Disabled
Are any of the dependents listed above covered by Medicare Part A or Part B?
If yes, please provide the following:
Name Medicare Number Part A Effective Date Part B Effective Date Medicare Reason
_______________________ ______________________ ___________________ ___________________ _____________________
_______________________ ______________________ ___________________ ___________________ _____________________
_______________________ ______________________ ___________________ ___________________ _____________________
Section F: Change Information
Add Enrollee: Open Enrollment Marriage Birth Adoption Loss of Coverage due to Divorce
Add Enrollee: Other: _______________________________ Requested Effective Date: _________________________________
Add Dependent(s): Open Enrollment Marriage Birth Adoption Other: ____________________________________
(List all dependents in Section E.) Qualifying Event/ Effective Date: ___________________________
Change Coverage: Base Coverage Select Coverage
Drop Dependent(s): Divorce Deceased Other: ________________________________________________________________
Provide information below for dependents to be dropped:
Name Social Security Number Requested Termination Date
___________________________________ ______________________ _____________________________________
___________________________________ ______________________ _____________________________________
___________________________________ ______________________ _____________________________________
___________________________________ ______________________ _____________________________________
Other Changes (Explain):
FOR EMPLOYER / ADMINISTRATOR USE ONLY: GROUP NUMBER:___________________________
New Legacy Employee, Requested Effective Date: _____________________________________________
New Horizon Employee, Requested Effective Date: _____________________________________________
Retiree, Requested Effective Date: ____________________________________________________________
COBRA, Requested Effective Date: ___________________________________________________________
Surviving Spouse, Requested Effective Date: ___________________________________________________
Change(s), Requested Effective Date: _________________________________________________________
ENTERED BY: __________________
DATE: _________________________
VERIFIED BY: ___________________
DATE: __________________________
Yes
No
Yes No
Legacy - Initially hired before 1/1/2006
Horizon - Initially hired on or after 1/1/2006
TOTAL EMPLOYEE TOTAL EMPLOYEE TOTAL EMPLOYEE TOTAL EMPLOYEE
ACTIVE EMPLOYEE PREMIUM PORTION PREMIUM PORTION PREMIUM PORTION PREMIUM PORTION
Employee* $389 $0 $409 $20 $389 $0 $430 $41
Employee + Spouse $814 $425 $893 $504 $814 $425 $914 $525
Employee + Spouse & Child(ren) $1,037 $648 $1,116 $727 $1,037 $648 $1,137 $748
Employee + Child $499 $110 $579 $190 $499 $110 $600 $211
Employee + Children $671 $282 $750 $361 $671 $282 $771 $382
RETIRED EMPLOYEE - NON-MEDICARE ELIGIBLE BASE SELECT BASE SELECT
Retiree $447 $470 $714 $739
Retiree + Spouse (Non-Medicare) $936 $1,026 $1,431 $1,524
Retiree + Spouse & Child(ren) (Non-Medicare) $1,192 $1,283 $1,600 $1,693
Retiree + Child $574 $640 $841 $909
Retiree + Children $771 $811 $1,038 $1,080
Retiree + Spouse (Medicare) N/A $666 N/A $935
Retiree + Spouse & Child(ren) (One or more Medicare) N/A $836 N/A $1,105
RETIRED EMPLOYEE - MEDICARE ELIGIBLE BASE SELECT BASE SELECT
Retiree N/A $196 N/A $196
Retiree + Spouse (Non-Medicare) N/A $752 N/A $981
Retiree + Spouse & Child(ren) (Non-Medicare) N/A $1,009 N/A $1,150
Retiree + Child N/A $366 N/A $366
Retiree + Children N/A $537 N/A $537
Retiree + Spouse (Medicare) N/A $392 N/A $392
Retiree + Spouse & Child(ren) (One or more Medicare) N/A $562 N/A $562
COBRA BASE SELECT BASE SELECT
Participant $396 $417 $396 $438
Participant + Spouse $830 $910 $830 $932
Participant + Spouse & Child(ren) $1,057 $1,138 $1,057 $1,159
Participant + Child $508 $590 $508 $612
Participant + Children $684 $765 $684 $786
COBRA DISABILITY EXTENSION BASE SELECT BASE SELECT
Participant $583 $613 $583 $645
Participant + Spouse $1,221 $1,339 $1,221 $1,371
Participant + Spouse & Child(ren) $1,555 $1,674 $1,555 $1,705
Participant + Child $748 $868 $748 $900
Participant + Children $1,006 $1,125 $1,006 $1,156
LEGACY
HORIZON
STATE AND SCHOOL EMPLOYEES' HEALTH INSURANCE PLAN
MONTHLY PREMIUM RATES
Effective January 1, 2021
LEGACY EMPLOYEES
HORIZON EMPLOYEES
BASE
SELECT
BASE
SELECT
*The State pays 100% of the employee's premium for Base Coverage. Active employees enrolling in Select Coverage must pay a portion of the employee
premium.
LEGACY RETIREES
HORIZON RETIREES
Enrollment/Change Request Form Page 1 of 2 MSLIFEAPP 12/2016
STATE AND SCHOOL EMPLOYEES’ LIFE INSURANCE PLAN
ENROLLMENT/CHANGE REQUEST FORM
Underwritten by Minnesota Life Insurance Company, an affiliate of Securian Financial Group, Inc.
Pol
icy 33683-G
SECTION A: Employee/Employer Information
Employee/Retiree Last Name: First Name: MI: Social Security Number: Birthdate: (MM/DD/YYYY):
Employee/Retiree Home Address:
Email Address:
Home Phone:
Alternate Phone:
Employer Name:
Employer Phone:
Employer Address:
SECTI
ON B: Coverage
(NOTE: For more information on available coverage, contact Minnesota Life toll free at 877-348-9217)
ACTIVE FULL-TIME EMPLOYEE: Life benefits and Accidental Death and Dismemberment (AD&D) maximums are based on two times
the employee’s annual wage rounded to the next higher one thousand dollars, subject to a minimum of $30,000 and a maximum of
$100,000. The employee and employer each pay 50 percent of the monthly premium.
New Employee – Applications made within initial 31 days of employment; coverage becomes effective on the first day of employment.
Late Enrollee Applicant – Applications made after initial 31 days of employment will be subject to medical evidence of insurability;
coverage will become effective on the first day of the month after or coincident with date of approval by Minnesota Life. (Employee
must also complete the Minnesota Life GROUP LIFE INSURANCE EVIDENCE OF INSURABILITY form.)
Date of Employment: _____________________
RETIRED EMPLOYEE: Life benefit amounts are limited to $5,000, $10,000 or $20,000. Retired employees are not eligible for AD&D
benefits. A retired employee should apply before, but no later than 31 days after the date active employee coverage terminates. A
retiree pays 100 percent of the monthly premium.
Date of Retirement: ______________________ COVERAGE AMOUNT REQUESTED: $5,000 $10,000 $20,000
DISABLED EMPLOYEE: Life benefit amounts are equal to employee’s current benefit level at the time coverage ceases as an active
employee. Disabled employees must apply no later than 31 days from the date active employee coverage terminates. Minnesota Life
is solely responsible for evaluating applications for coverage continuation. Premiums are waived after the first nine months.
(Employee must also complete the Minnesota Life NOTICE OF DISABILITY and ATTENDING PHYSICIAN’S STATEMENT forms.)
Date of Disability: ______________________
SECTI
ON C: Beneficiary Information
NOTE: You cannot designate your life insurance beneficiary on this form. To designate your life insurance beneficiary, please follow
the instructions below:
1. Log in to your myBlue site, https://myblue.bcbsms.com, and click on the My Benefits tab.
2. Scroll down to the Life Benefits section below Medical Benefits. This section will show you the effective date and amount of life
insurance coverage you have.
3. Click the link in the Life Benefits section and you will be redirected to Minnesota Life’s online beneficiary management tool. Follow
the instructions on the site to submit your beneficiary designation.
Once you submit your beneficiary information, a confirmation statement will be mailed to you. You may view or update your beneficiary
information any time by accessing Minnesota Life's website through the myBlue portal.
If you do not designate a life insurance beneficiary, any resulting life insurance benefits will be paid according to the defaults set
forth in the policy.
If you do not have Internet access, contact Minnesota Life toll free at 877-348-9217 to request a paper beneficiary designation form.
Enrollment/Change Request Form Page 2 of 2 MSLIFEAPP 12/2016
SECTI
ON D: Authorization and Certification
I am appl
ying for group term life insurance for myself through the State and School Employees’ Life Insurance Plan (Plan). I
understand that if my application is approved, coverage will become effective on the date fixed by the Plan or Minnesota Life.
I certify that all information on this form is true and complete to the best of my knowledge and belief. I understand that this
insurance is subject to all of the terms of the Plan of Insurance contained in the Minnesota Life Insurance Company, Group
Policy #33683-G, and summarized in the Certificate of Coverage provided to me. I understand that any misrepresentation by
me may result in the cancellation or rescission of coverage under the Plan.
I understand that if I am a late enrollee applicant, any insurance subject to evidence of good health or medical information will
not become effective until Minnesota Life gives its written consent. I understand that my eligibility may be affected in the event
I fail to sign this form within 31 days of the effective date of eligibility, or if for any reason my employer does not receive the
Enrollment/Change Request Form within a reasonable time following the event.
I understand and authorize that the appropriate premiums for the coverage requested will be deducted from my wages or
retirement benefits, as appropriate, and authorize release of employment and payroll information or other such eligibility
information to the Plan and/or Minnesota Life as needed to verify my eligibility, benefit amounts, or other such information
necessary in the proper administration of the Plan.
Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals, for the purpose of
misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects
such person to criminal and civil penalties.
______________________________________________ ___________________________________
Employee/Retiree Signature (Required) Date
SECTION E: Waiver/Request to Cancel Coverage (Only complete this section to waive or cancel coverage.)
Waiver of Coverage – I hereby decline to apply for life insurance coverage in the State and School Employees’ Life
Insurance Plan. I understand that an active employee who waives coverage in the Plan may apply for coverage at a later
date so long as he continues to qualify as an active employee. I further understand that late enrollee applicants are subject
to medical evidence of insurability that may result in coverage being denied. I understand that a service retired employee
or totally disabled employee who declines to apply for continuation of coverage in the Plan within 31 days of the date his
coverage ceases as an active employee, forfeits his right to participate in the State and School Employees’ Life Insurance
Plan and will not be allowed to apply at a later date.
Cancellation of Coverage – I hereby request that my life insurance coverage in the State and School Employees’ Life
Insurance Plan be cancelled. I understand that an active employee who cancels his coverage in the Plan may apply for
coverage at a later date so long as he continues to qualify as an active employee. I further understand that late enrollee
applicants are subject to medical evidence of insurability that may result in coverage being denied. I understand that a
service retired employee or totally disabled employee who cancels his coverage in the Plan forfeits his right to participate
in the State and School Employees’ Life Insurance Plan and will not be allowed to apply at a later date.
SIGN BELOW ONLY IF YOU DO NOT WANT LIFE INSURANCE COVERAGE.
______________________________________________ ___________________________________
Employee/Retiree Signature Date
FOR QUESTIONS REGARDING THE STATE AND SCHOOL EMPLOYEES’ LIFE INSURANCE PLAN, VISIT THE PLAN’S WEBSITE AT
http://KnowYourBenefits.dfa.ms.gov/
OR CONTACT THE DFA-OFFICE OF INSURANCE AT 866-586-2781.
FOR PERSONNEL/PAYROLL USE ONLY
COVERAGE AMOUNT:
REQUESTED EFFECTIVE DATE:
GROUP NUMBER:
INFORMATION VERIFIED: (INITIAL AND DATE)
Employee/Retiree Last Name
First Name
MI
Social Security Number
Daytime Phone
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
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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Completed 3 February 2021

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