Fill - Form W-4: Employees Withholding Certificate

Form W-4

(Rev. December 2020)

Department of the Treasury

Internal Revenue Service

Employee’s Withholding Certificate

▶

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

▶

Give Form W-4 to your employer.

▶

Your withholding is subject to review by the IRS.

OMB No. 1545-0074

2021

Step 1:

Enter

Personal

Information

(a) First name and middle initial Last name

Address

City or town, state, and ZIP code

(b) Social security number

▶

Does your name match the

name on your social security

card? If not, to ensure you get

credit for your earnings, contact

SSA at 800-772-1213 or go to

www.ssa.gov.

(c)

Single or Married filing separately

Married filing jointly or Qualifying widow(er)

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can

claim exemption from withholding, when to use the 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 . . . . .

▶

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

▶

Multiply the number of other dependents

by $500 . . . .

▶

Add the amounts above and enter the total here . . . . . . . . . . . . .

3 $

Step 4

(optional):

Other

Adjustments

(a)

Other income (not from jobs). If you want tax withheld for other income you expect

this year that won’t have withholding, enter the amount of other income here. This may

include interest, dividends, and retirement income . . . . . . . . . . . .

4(a) $

(b)

Deductions. If you expect to claim deductions other than the standard deduction

and want to reduce your withholding, use the Deductions Worksheet on page 3 and

enter the result here . . . . . . . . . . . . . . . . . . . . .

4(b) $

4(c)

Step 5:

Sign

Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

▲

Employee’s signature (This form is not valid unless you sign it.)

▲

Date

Employers

Only

Employer’s name and address First date of

employment

Employer identification

number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3.

Cat. No. 10220Q

Form W-4 (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.

▲

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.

Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one

job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the

“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter

that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $

2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and

2c below. Otherwise, skip to line 3.

Find the amount from the appropriate table on page 4 using the annual wages from the highest

paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job

in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries

and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a $

Add the annual wages of the two highest paying jobs from line 2a together and use the total as the

wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower

Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount

on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2b $

c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c

3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays

weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this

amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional

amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $

Step 4(b)—Deductions Worksheet (Keep for your records.)

Enter an estimate of your 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

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:

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.

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