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

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

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USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
a
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
a
Give Form W-4 to your employer.
a
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
a
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld .....
a
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
a
$
Multiply the number of other dependents
by $500 . . . .
a
$
Add the amounts above and enter the total here .............
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b)
Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here .....................
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
F
Employee’s signature (This form is not valid unless you sign it.)
F
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2020)
click to sign
signature
click to edit
Form W-4 (2020)
Page 2
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you will
generally be due a refund. Complete a new Form W-4 when
changes to your personal or financial situation would change
the entries on the form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
Exemption from withholding. You may claim exemption from
withholding for 2020 if you meet both of the following
conditions: you had no federal income tax liability in 2019 and
you expect to have no federal income tax liability in 2020. You
had no federal income tax liability in 2019 if (1) your total tax on
line 16 on your 2019 Form 1040 or 1040-SR is zero (or less
than the sum of lines 18a, 18b, and 18c), or (2) you were not
required to file a return because your income was below the
filing threshold for your correct filing status. If you claim
exemption, you will have no income tax withheld from your
paycheck and may owe taxes and penalties when you file your
2020 tax return. To claim exemption from withholding, certify
that you meet both of the conditions above by writing “Exempt”
on Form W-4 in the space below Step 4(c). Then, complete
Steps 1(a), 1(b), and 5. Do not complete any other steps. You
will need to submit a new Form W-4 by February 16, 2021.
Your privacy. If you prefer to limit information provided in
Steps 2 through 4, use the online estimator, which will also
increase accuracy.
As an alternative to the estimator: if you have concerns
with Step 2(c), you may choose Step 2(b); if you have
concerns with Step 4(a), you may enter an additional amount
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box
in Step 2(c), which will increase your withholding and
significantly reduce your paycheck (often by thousands of
dollars over the year).
When to use the estimator. Consider using the estimator at
www.irs.gov/W4App if you:
1. Expect to work only part of the year;
2. Have dividend or capital gain income, or are subject to
additional taxes, such as the additional Medicare tax;
3. Have self-employment income (see below); or
4. Prefer the most accurate withholding for multiple job
situations.
Self-employment. Generally, you will owe both income and
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an
employee. If you want to pay these taxes through
withholding from your wages, use the estimator at
www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice
1392, Supplemental Form W-4 Instructions for Nonresident
Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
compute your withholding.
Step 2. Use this step if you (1) have more than one job at the
same time, or (2) are married filing jointly and you and your
spouse both work.
Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
little less accuracy.
If you (and your spouse) have a total of only two jobs, you
may instead check the box in option (c). The box must also be
checked on the Form W-4 for the other job. If the box is
checked, the standard deduction and tax brackets will be cut
in half for each job to calculate withholding. This option is
roughly accurate for jobs with similar pay; otherwise, more tax
than necessary may be withheld, and this extra amount will be
larger the greater the difference in pay is between the two jobs.
F
!
CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. Step 3 of Form W-4 provides instructions for
determining the amount of the child tax credit and the credit
for other dependents that you may be able to claim when
you file your tax return. To qualify for the child tax credit, the
child must be under age 17 as of December 31, must be
your dependent who generally lives with you for more than
half the year, and must have the required social security
number. You may be able to claim a credit for other
dependents for whom a child tax credit can’t be claimed,
such as an older child or a qualifying relative. For additional
eligibility requirements for these credits, see Pub. 972, Child
Tax Credit and Credit for Other Dependents. You can also
include other tax credits in this step, such as education tax
credits and the foreign tax credit. To do so, add an estimate
of the amount for the year to your credits for dependents
and enter the total amount in Step 3. Including these credits
will increase your paycheck and reduce the amount of any
refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other
estimated income for the year, if any. You shouldn’t include
income from any jobs or self-employment. If you complete
Step 4(a), you likely won’t have to make estimated tax
payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5, if you expect to claim deductions other than
the basic standard deduction on your 2020 tax return and
want to reduce your withholding to account for these
deductions. This includes both itemized deductions and other
deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want
withheld from your pay each pay period, including any
amounts from the Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund or reduce any amount of tax that you owe.
Form W-4 (2020)
Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 ..................... 1
$
2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a ....................... 2a
$
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b .............................
2b $
c Add the amounts from lines 2a and 2b and enter the result on line 2c .......... 2c
$
3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. ..... 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) ......................... 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1
Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and local
taxes (up to $10,000), and medical expenses in excess of 7.5% of your income ....... 1 $
2 Enter:
{
• $24,800 if you’re married filing jointly or qualifying widow(er)
• $18,650 if you’re head of household
• $12,400 if you’re single or married filing separately
}
........ 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . 3 $
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information 4
$
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 ........... 5 $
Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. Internal
Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to
provide this information; your employer uses it to determine your federal income
tax withholding. Failure to provide a properly completed form will result in your
being treated as a single person with no other entries on the form; providing
fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws; and to the Department of
Health and Human Services for use in the National Directory of New Hires. We
may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
Form W-4 (2020)
Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870
$10,000 - 19,999
220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070
$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900
$30,000 - 39,999
900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100
$40,000 - 49,999
1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220
$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220
$60,000 - 69,999
1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220
$70,000 - 79,999
1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240
$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180
$150,000 - 239,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250
$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170
$260,000 - 279,999
2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770
$280,000 - 299,999
2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370
$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970
$320,000 - 364,999
2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840
$365,000 - 524,999
2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280
$525,000 and over
3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040
$10,000 - 19,999
940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830
$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110
$30,000 - 39,999
1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310
$40,000 - 59,999
1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080
$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060
$80,000 - 99,999
2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060
$100,000 - 124,999
2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620
$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370
$150,000 - 174,999
2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120
$175,000 - 199,999
2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230
$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$250,000 - 399,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930
$400,000 - 449,999
2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540
$450,000 and over
3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040
$10,000 - 19,999
830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440
$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850
$30,000 - 39,999
1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140
$40,000 - 59,999
1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380
$80,000 - 99,999
1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380
$100,000 - 124,999
2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870
$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620
$150,000 - 174,999
2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370
$175,000 - 199,999
2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980
$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$250,000 - 349,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870
$350,000 - 449,999
2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200
$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240
)RUP85HY
0,66,66,33,(03/2<((6:,7++2/',1*(;(037,21&(57,),&$7(
(PSOR\HHV1DPH 661
(PSOR\HHV5HVLGHQFH
$GGUHVV
0DULWDO6WDWXV
(03/2<((
6LQJOH
)LOHWKLVIRUPZLWK\RXU
HPSOR\HU. Otherwise, you
must withhold Mississippi
income tax from the full
amount of your wages.
(03/2<(5
.HHSWKLVFHUWLILFDWHZLWK
\RXUUHFRUGV. If the
employee is believed to
have claimed excess
exemption, the Department
of Revenue should be
advised.
3HUVRQDO([HPSWLRQ$OORZHG
&/$,0<285:,7++2/',1*3(5621$/(;(037,21
$PRXQW&ODLPHG
Enter $6,000 as exemption . . . . f
0LVVLVVLSSL'HSDUWPHQWRI5HYHQXH
32 %R[
-DFNVRQ06
1XPEHUDQG6WUHHW &LW\RU7RZQ
6WDWH
=LS &RGH
&KHFN2QH
(a)
(b)
Spouse 127 employed: Enter $12,000
f
Spouse ,6 employed: Enter that part of
$12,000 claimed by you in multiples of
$500. See instructions 2(b) below .f
0DULWDO 6WDWXV
+HDGRI)DPLO\
Enter $9,500 as exemption. To qualify
as head of family, you must be single
and have a dependent living in the
home with you. See instructions 2(c)
and 2(d)below . . . . . . . . . . . .f
You may claim $1,500 for each dependent, other than
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.
6
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
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
ACTIVE EMPLOYEE
LEGACY EMPLOYEES
HORIZON EMPLOYEES
BASE
SELECT
BASE
SELECT
TOTAL
PREMIUM
EMPLOYEE
PORTION
TOTAL
PREMIUM
EMPLOYEE
PORTION
TOTAL
PREMIUM
EMPLOYEE
PORTION
TOTAL
PREMIUM
EMPLOYEE
PORTION
Employee *
$367
$0
$387
$20
$367
$0
$406
$39
Employee + Spouse
$768
$401
$843
$476
$768
$401
$862
$495
Employee + Spouse & Child(ren)
$978
$611
$1,053
$686
$978
$611
$1,072
$705
Employee + Child
$471
$104
$547
$180
$471
$104
$566
$199
Employee + Children
$633
$266
$708
$341
$633
$266
$727
$360
RETIRED EMPLOYEE - NON-MEDICARE ELIGIBLE
LEGACY RETIREES
HORIZON RETIREES
BASE
SELECT
BASE
SELECT
Retiree
$421
$445
$673
$696
Retiree + Spouse (Non-Medicare)
$881
$969
$1,349
$1,436
Retiree + Spouse & Child(ren) (Non-Medicare)
$1,123
$1,211
$1,508
$1,595
Retiree + Child
$540
$605
$792
$856
Retiree + Children
$727
$766
$979
$1,017
Retiree + Spouse (Medicare)
N/A
$633
N/A
$884
Retiree + Spouse & Child(ren) (One or more Medicare)
N/A
$793
N/A
$1,044
RETIRED EMPLOYEE - MEDICARE ELIGIBLE
BASE
SELECT
BASE
SELECT
Retiree
N/A
$188
N/A
$188
Retiree + Spouse (Non-Medicare)
N/A
$712
N/A
$928
Retiree + Spouse & Child(ren) (Non-Medicare)
N/A
$954
N/A
$1,087
Retiree + Child
N/A
$348
N/A
$348
Retiree + Children
N/A
$509
N/A
$509
Retiree + Spouse (Medicare)
N/A
$376
N/A
$376
Retiree + Spouse & Child(ren) (One or more Medicare)
N/A
$536
N/A
$536
COBRA
BASE
SELECT
BASE
SELECT
Participant
$374
$394
$374
$414
Participant + Spouse
$783
$859
$783
$879
Participant + Spouse & Child(ren)
$997
$1,074
$997
$1,093
Participant + Child
$480
$557
$480
$577
Participant + Children
$645
$722
$645
$741
COBRA DISABILITY EXTENSION
BASE
SELECT
BASE
SELECT
Participant
$550
$580
$550
$609
Participant + Spouse
$1,152
$1,264
$1,152
$1,293
Participant + Spouse & Child(ren)
$1,467
$1,579
$1,467
$1,608
Participant + Child
$706
$820
$706
$849
Participant + Children
$949
$1,062
$949
$1,090
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
For Office of Information Technology use only
Sent FERPA Email – Done by: ______________________________________________
Sent Policies & Procedures Email – Done by: __________________________________
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Form I-9: Employment Eligibility Verification (Mississippi Delta Community College)

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Completed 19 September 2020

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