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HUMAN RESOURCES DEPARTMENT (Pensacola State College)

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HUMAN RESOURCES DEPARTMENT
Adjunct Packet
(Ready-To-Hire)
Participant’s Name
Employ
ee’s ID Number,
if known
Department Name
Depart
ment Head
Note: Only Completed Packets, for individuals intended to be hired, should be
sent to the Human Resources Department
at the Pensacola Campus, Building 7, Room 715.
Rev. 04/2019
DEPARTMENT HEAD ACKNOWLEDGEMENT FORM
DATE:
TO: Hum
an Resources Department
FROM:
Name
of Department Head
RE: P
acket for:
Enclosed is the completed packet for the participant named above. This packet is to be
forwarded to Human Resources for individuals intended to be hired. This packet includes the
following documents:
1. Adjunct Acknowledgement Form
2. Department Head Acknowledgement Form
3. Pensacola State College Employment Application
4. Notification of Social Security Number Collection and Usage
5. Employee Emergency Contact Form
6. Self-Identification Information Form
7. Employee’s Withholding Allowance Certificate (Form W-4)
8. Direct Deposit Form
9. Employment Eligibility Verification (Form I-9)
10. Criminal Background Check/Fingerprinting Instructions
11. Payroll Deduction Authorization Form for Background Check
12. FDLE VECHS Waiver Form
13. FRS Retirement Status Certification Form
14. Loyalty Oath
15. Transcript Agreement Form
16. Transcript Request Form(s)
17. Worker’s Compensation
18. Social Security Withholding BENCOR – 401(a) FICA Alternative Plan
Department Head Signature Date
Rev. 03/2020
Adjunct Acknowledgement Form
DATE:
TO: Hum
an Resources Department
FROM:
Nam
e of Adjunct Instructor
I acknowledge the receipt and the return of the appropriate documents as listed herein. It is my
understanding that these documents or the acknowledgement thereof will become part of my human
resources file. I understand that the processing of my contract for employment is contingent upon
the receipt and set-up of a completed adjunct packet.
The docu
ments listed below constitute a complete adjunct packet. My signature below acknowledges
that I have received, reviewed, and/or returned these documents to appropriate college staff
member. (Place a check mark () in the appropriate spaces):
1. Adjunct Acknowledgement Form
2. Department Head Acknowledgement Form
3. Pensacola State College Employment Application
4. Notification of Social Security Number Collection and Usage
5. Employee Emergency Contact Form
6. Self-Identification Information Form
7. Employee’s Withholding Allowance Certificate (Form W-4)
8. Direct Deposit Form
9. Employment Eligibility Verification (Form I-9)
10. Criminal Background Check/Fingerprinting Instructions
11. Payroll Deduction Authorization Form for Background Check
12. FDLE VECHS Waiver Form
13. FRS Retirement Status Certification Form
14. Loyalty Oath
15. Transcript Agreement Form
16. Transcript Request Form(s)
17. Worker’s Compensation
18. Social Security Withholding BENCOR – 401(a) FICA Alternative Plan
Adjunct Signature Date
Rev. 03/2020
An Equal Access/Equal Opportunity Employer
Human Resources Department
1000 College Boulevard
Pensacola, FL 32504
Phone: (850) 484-1799 Fax: (850) 484-1711
EMPLOYMENT APPLICATION
• Copy of post-secondary transcripts required for executive, faculty, professional/managerial, and adjunct positions.
• Type or print in blue or black ink.
• Complete all sections in detail and sign the application.
• Submit a separate application for each vacancy.
• A resume may be attached but is not accepted in lieu of completing all sections of this form.
• Accurate information provides an evaluation of your qualifications; information provided is subject to verification.
• If special assistance or accommodations are needed during the application/interview process, contact the Human
Resources Department.
Position:
Date:
Check one:
☐
Career Service
☐
Executive
☐
Faculty Professional/Managerial
☐
Adjunct
APPLICANT INFORMATION
1. Name
First
Middle
2. Social Security Number (Last 4 digits only)
3. Telephone
Home Phone
Work Phone
Cell Phone
4. Address
Street Address
__________________________________________________________________________________________
City
State
Zip
E-mail Address
5.
Are you legally authorized to work in the United States? ☐ Yes ☐ No
7.
Have you ever been emp
loyed by a Florida Community College or Florida State Agency? ☐ Yes
☐No
If yes, which college or agency, and when?
8. Have you ever been convicted of a felony? ☐Yes ☐ No
If yes, please explain:_______________________________________________________________________
9.
Have you ever had a license suspended or revoked? ☐Yes ☐ No
If yes, please explain:______________________________________________________________________
10.
Please list any other name(s) you may be known by:
11.
Where did you learn of this job opening?
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex, age, religion,
marital status, pregnancy, disability, sexual orientation or genetic information in its educational programs, activities, or employment. For inquiries
regarding Title IX and the college's nondiscrimination policies, contact the Director of Institutional Diversity/Title IX at (850) 484-1759, Pensacola
State College, 1000 College Boulevard, Pensacola, Florida 32504.
Rev. 04/2019
6.
Will you now or in the future require sponsorship for employment visa status (e.g., E-3, H-1B, O-1, TN, etc. visa
status)?
☐Yes
☐No
The College does not usually sponsor applicants for work visas.
EDUCATION
Photocopies of post-secondary transcripts are required for executive, faculty, and professional/managerial
positions. Transcripts may also be required for certain career service positions
as listed in the minimum
qualifications
(see job description for details). Official transcripts may be required later in the process; official
transcripts will not be returned. Transcripts must document the appropriate degree awarded as required in the
minimum qualifications.
School Name and Location Graduated Dates Attended
Type of
Degree Earned
High School
☐
Yes
☐
No
Junior/Community
College
Year Graduated
College and/or University
Year Graduated
Graduate/Post-Graduate School
Year Graduated
CERTIFICATIONS/LICENSURES (Please include last renewal date.)
PUBLICATIONS
REFERENCES
List three people, other than relatives, who have knowledge of your professional or educational background. May
we contact your present employer for a reference? ☐Yes ☐ No
Name Position/Title Daytime Phone Number
1.
Address
2.
Address
3.
Address
EMPLOYMENT EXPERIENCE
List all employment, starting with the
most recent employer. Account for all periods including unemployment.
Provide a detailed description of your skills as related to the minimum qualifications for the position applied for.
Employer
Dates Employed
Address
Job Title
Supervisor
☐Full-Time ☐ Part-Time Hours per Week
Salary
Duties
Reason for Leaving
Employer
Dates Employed
Address
Job Title
Supervisor
☐Full-Time ☐ Part-Time Hours per Week
Salary
Duties
Reason for Leaving
Employer
Dates Employed
Address
Job Title
Supervisor
☐Full-Time ☐ Part-Time Hours per Week
Salary
Duties
Reason for Leaving
EMPLOYMENT EXPERIENCE (continued)
List all employment, starting with the most recent employer. Account for all periods including unemployment.
Provide a detailed description of your skills as related to the minimum qualifications for the position applied for.
Employer
Dates Employed
Address
Job Title
Supervisor
☐Full-Time ☐ Part-Time Hours per Week
Salary
Duties
Reason for Leaving
Employer
Dates Employed
Address
Job Title
Supervisor
☐Full-Time ☐ Part-Time Hours per Week
Salary
Duties
Reason for Leaving
APPLICANT’S CERTIFICATION
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize the
investigation of all matters contained in this application and resume, if applicable, and give the College permission
to contact schools, previous employers, references, and others, and hereby release the College from any liability as
a result of such contact. I understand that misrepresentations, omission of facts, or incomplete information in this
application may eliminate me from employment consideration.
In addition, if employed, any misrepresentation or omission of facts given in this application may be cause for
termination of employment.
Applicant’s Signature
Date
Notification of Social Security Number Collection and Use
In compliance with Section 119.071(5), Florida Statutes, Pensacola State College issues this notification regarding the purpose
for the collection and use of your Social Security Number (SSN). Pensacola State College collects and uses your SSN only to
perform the College duties and responsibilities. To protect your identity, Pensacola State will maintain the privacy of your SSN
and never release it to unauthorized parties in compliance with state and federal laws. The College assigns you a unique
student/employee identification number which is used for associated employment and educational purposes at Pensacola
State, including the access of your college records.
Pensacola St
ate College may collect and/or use your Social Security Number for the following purposes:
PURPOSE FEDERAL AND STATE REGULATIONS
EMPLOYEES
Human Resources (Employment and Hiring)
SSNs are used for legitimate business purposes in compliance with
completion and processing of the following:
•
Federal I-9 (Department of Homeland Security)
•
Federal W4, W2, 1099 (Internal Revenue Service)
•
Federal Social Security taxes (FICA)
•
Processing and Distributing Federal W2 (Internal Revenue Service)
•
Unemployment Reports (FL Dept. of Revenue)
•
Florida Retirement Contribution reports (FL Dept. of Revenue)
•
Workers Comp Claims (FCCRMC and Department of Labor)
•
Direct Deposit Files (affiliate banks)
•
403b and 457b contribution reports
•
Group health, life and dental coverage enrollment (for employees
and their dependents)
•
Various supplemental insurance deduction reports
•
Background checks (SSNs are collected in conducting
employment background investigations for prospective
employees as well as promotion eligible employees pursuing
positions of special trust)
•
Retirement documents (for retirees, employees and their
beneficiaries)
•
Certain federal contracts/grants require SSN for equity and IRS
reporting
•
Tax-related uses are authorized
and/or required by
O 26 USC 3402, 3406, 1441,
6109 & 1.6011(b)-2;
O
8 USC 1324a;
O and 20 CFR 4.452
•
Benefits-related uses are authorized by
119.071(5)(a)6.b.,f.,g, F.S
•
Background/employment-related uses
are required by 8 USC 1324(a) and 42
USC 653(a)
•
Worker Compensation Claims are
authorized by 440.185, F.S., Department
of Labor, FCCRMC
•
Unemployment uses are authorized
by State of Florida; disclosure per
119.071(5)(a)6.b., F.S.
•
Retirement uses are authorized by
Florida Department of Revenue;
disclosure per 119.071(5)(a)6.b., F.S.
•
Health insurance uses are authorized
by State of Florida: disclosure per
119.071(5)(a)6.f.F.S.
•
Federal Contracts/Grants reporting
use authorized by 41 CFR 60-4.3
•
403(b) contribution reporting
authorized by US Tax Code 501(c)(3)
Providing your social security number is a condition of employment at Pensacola State College.
_____________________________ _________________
Employee Signature Date
Attach copy of
SS card here.
Rev. 04/2019
EMERGENCY CONTACT FORM
Employee Name _ ___________________________ __________ ______
Address _________________________________________________________
_________________________________________________________
Phone N
umber ___________________________________________________
Employee ID Number _________ _ ____________________
In case of an emergency, please contact:
Contact Person No. 1:
Name ___________________________________________________________
Relationship to Employee ___________________________________________
Address _________________________________________________________
_________________________________________________________
Phone Number _____________________ (Work) _______________________
Contact Person No. 2:
Name ___________________________________________________________
Relationship to Employee ___________________________________________
Address _________________________________________________________
_________________________________________________________
Phone N
umber _____________________ (Work) _______________________
Updates or changes to your Emergency Contacts may be processed at:
e-Human Re
sources > Employee Web Access > Directory Information
Rev. 04/2019
Please provide the following information for your employee record.
ETHNIC BACKGROUND
________ American Indian or Alaskan Native
__
______ Asian
________ Black or
African American (not Hispanic origin)
________ Hispanic or Latina
________ Native Hawaiian or Other Pacific Islander
________ White (not Hispanic origin)
GENDER
DISABLED
VETERAN
________ Female
________ Yes
________ Yes
_______ Male
_______ No
_______ No
Signature Date
Rev
. 02/2020
MARITAL STATUS
EMPLOYEE NAME: _____________________________________________
Self-Identification Information
SOCIAL SECURITY NUMBER:
DATE OF BIRTH:
Single
Married
Pensacola State College does not discriminate against any person on the basis of race, ethnicity, national origin, color, gender/sex,
religion, marital status, pregnancy, disability, sexual orientation, or genetic information in its educational programs, activities, or
employment. For inquiries regarding Title IX and the college's nondiscrimination policies, contact the Director of Institutional
Diversity/Title IX at 850-484-1759, Pensacola State College, 1000 College Boulevard, Pensacola, Florida 32504.
AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS
(ACH CREDITS)
Employment Status: Full-Time Adjunct Student
Employee Name: Employee ID#
Department
:
Telephone:
I
HEARBY AUTHORIZE PENSACOLA STATE COLLEGE TO INITIATE CREDIT ENTRIES AND TO INITIATE, IF NECESSARY, DEBIT ENTRIES
AND ADJUSTMENTS FOR ANY CREDIT ENTRIES IN ERROR TO MY
:
DEPOSIT
Type of Request New Set-Up Change Cancellation
Account Type Checking Savings
Financial Institution Name
Branch Number
Branch Location
Financial Institution Phone Number
Account Number
ABA Routing Number
VOIDED CHECK OR DIRECT DEPOSIT ENROLLMENT FORM MUST BE ATTACHED (except for cancellations)
This authority is to remain in full force and effect until Pensacola State College has received written notification from me of
its termination in such time and in such manner as to afford Pensacola State College and the financial institution a
reasonable opportunity to act on it.
Note: In an effort to expedite the efficient processing of your direct deposit request, the direct deposit is set up
as a pre-
note. This allows Pensacola State College and the financial institution the opportunity to ensure that all
information is
transmitted accurately. Therefore a hard copy (paper) check is issued for the pay period following the initial direct deposit
set-up and must be picked up from the Cashier's Office. For changes to direct deposit - the payroll check is mailed to the
employee address on file.
(Please Initial)
I
acknowledge that my first pay-check will be a paper check that has to be picked up from
the Bursar’s
office on any of our three campuses. Please indicate which location you prefer.
First check p
ick up location:
PENSACOLA MILTON
WARRINGTON
Signature: Date:
Human Resources Department
1000 College Blvd., Pensacola, FL 32504
Phone: (850) 484-1760 Fax: (850) 484-1711
Revised 09/2019
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.
Instructions for Form I-9,
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employers must complete Form I-9 to document verification of the identity and employment authorization of each new
employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the
Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment
authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011.
What is the Purpose of This Form?
Anti-Discrimination Notice. It is illegal to discriminate against work-authorized individuals in hiring, firing, recruitment or
referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's
citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) the employee may
present to establish employment authorization. The employer must allow the employee to choose the documents to be presented
from the Lists of Acceptable Documents, found on the last page of Form I-9. The refusal to hire or continue to employ an
individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more
information, contact the Immigrant and Employee Rights Section (IER) in the Department of Justice's Civil Rights Division at
https://www.justice.gov/ier.
General Instructions
The term “Employee” does not include
those who do not receive any form of remuneration (volunteers), independent contractors or those engaged in certain casual
domestic employment.
These instructions will assist you in properly completing Form I-9. The employer must ensure that all pages of the instructions
and Lists of Acceptable Documents are available, either in print or electronically, to all employees completing this form. When
completing the form on a computer, the English version of the form includes specific instructions for each field and drop-down
lists for universally used abbreviations and acceptable documents. To access these instructions, move the cursor over each field
instructions at any time by clicking the Instructions button at the top of each page when completing the form on a computer that
is connected to the Internet.
Employers and employees may choose to complete any or all sections of the form on paper or using a computer, or a
combination of both. Forms I-9 obtained from the USCIS website are not considered electronic Forms I-9 under DHS
regulations and, therefore, cannot be electronically signed. Therefore, regardless of the method you used to enter information
into each field, you must print a hard copy of the form, then sign and date the hard copy by hand where required.
Employers can obtain a blank copy of Form I-9 from the USCIS website at https://www.uscis.gov/i-9. This form is in portable
document format (.pdf) that is fillable and savable. That means that you may download it, or simply print out a blank copy to
enter information by hand. You may also request paper Forms I-9 from USCIS.
Certain features of Form I-9 that allow for data entry on personal computers may make the form appear to be more than two
pages. When using a computer, Form I-9 has been designed to print as two pages. Using more than one preparer and/or
translator will add an additional page to the form, regardless of your method of completion. You are not required to print, retain
or store the page containing the Lists of Acceptable Documents.
Page 1 of 15Form I-9 Instructions 10/21/2019
You, the employee, must complete each field in Section 1 as described below. Newly hired employees must complete and sign
Section 1 no later than the first day of employment. Section 1 should never be completed before you have accepted a job offer.
Completing Section I: Employee Information and Attestation
Page 2 of 15Form I-9 Instructions 10/21/2019
Last Name : Enter your full legal last name. Your last name is your family name or surname. If you have two
last names or a hyphenated last name, include both names in the Last Name field. Examples of correctly entered last names
include: De La Cruz, O’Neill, Garcia Lopez, Smith-Johnson, Nguyen. If you only have one name, enter it in this field, then
enter “Unknown” in the First Name field. You may not enter “Unknown” in both the Last Name field and the First Name field.
First Name : Enter your full legal first name. Your first name is your given name. Some examples of correctly
entered first names include: Jessica, John-Paul, Tae Young, D’Shaun, Mai. If you only have one name, enter it in the Last
Name field, then enter “Unknown” in this field. You may not enter “Unknown” in both the First Name field and the Last Name
field.
Middle Initial: Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any.
If you have more than one middle name, enter the first letter of your first middle name. If you do not have a middle name, enter
N/A in this field.
Other Last Names Used: Provide all other last names used, if any (e.g., maiden name). Enter N/A if you have not used other
last names. For example, if you legally changed your last name from Smith to Jones, you should enter the name Smith in this
field.
Address ( ): Enter the street name and number of the current address of your residence. If you are a
border commuter from Canada or Mexico, you may enter your Canada or Mexico address in this field. If your residence does
not have a physical address, enter a description of the location of your residence, such as “3 miles southwest of Anytown post
office near water tower.”
Apartment:
State: Enter the abbreviation of your state or territory in this field. If you are a border commuter from Canada or Mexico, enter
your country abbreviation in this field.
ZIP Code: Enter your 5-digit ZIP code. If you are a border commuter from Canada or Mexico, enter your
5- or 6-digit postal code in this field.
Date of Birth ( ): Enter your date of birth as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For
example, enter January 8, 1980 as 01/08/1980.
U.S. Social Security Number: Providing your 9-digit Social Security number is voluntary on Form I-9 unless your employer
participates in E-Verify. If your employer participates in E-Verify and:
1. You have been issued a Social Security number, you must provide it in this field; or
2. You have applied for, but have not yet received a Social Security number, leave this field blank until you receive
a Social Security number.
The form will also populate certain fields with N/A when certain user choices ensure that particular fields will not be
completed. The Print button located at the top of each page that will print any number of pages the user selects. Also, the Start
Over button located at the top of each page will clear all the fields on the form.
The Spanish version of Form I-9 does not include the additional instructions and drop-down lists described above. Employers
in Puerto Rico may use either the Spanish or English version of the form. Employers outside of Puerto Rico must retain the
English version of the form for their records, but may use the Spanish form as a translation tool.
Handbook for Employers: Guidance for Completing Form I-9 (M-274) and on USCIS
Form I-9 website, I-9 Central.
You must select one box to attest to your citizenship or immigration status.
1. A citizen of the United States.
2. A noncitizen national of the United States:
An individual born in American Samoa, certain former citizens of the
former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.
3. A lawful permanent resident:
If you select “lawful permanent resident,” enter your 7- to 9-digit Alien Registration Number (A-Number), including the
“A,” or USCIS Number in the space provided. When completing this field using a computer, use the dropdown provided
to indicate whether you have entered an Alien Number or a USCIS Number. At this time, the USCIS Number is the same
as the A-Number without the “A” prefix.
4. An alien authorized to work: An individual who is not a citizen or national of the United States, or a lawful permanent
resident, but is authorized to work in the United States.
1. Alien Registration Number (A-Number)/USCIS Number; or
2. Form I-94 Admission Number; or
3. Foreign Passport Number and the Country of Issuance.
Alien Registration Number/USCIS Number: Enter your 7- to 9-digit Alien Registration Number (A-Number),
including the “A,” or your USCIS Number in this field. At this time, the USCIS Number is the same as your
A-Number without the “A” prefix. When completing this field using a computer, use the dropdown provided to indicate
whether you have entered an Alien Number or a USCIS Number. If you do not provide an A-Number or USCIS Number,
enter N/A in this field then enter either a Form I-94 Admission Number, or a Foreign Passport and Country of Issuance in
the fields provided.
Form I-94 Admission Number: Enter your 11-digit I-94 Admission Number in this field. If you do not provide an I-94
Admission Number, enter N/A in this field, then enter either an Alien Registration Number/USCIS Number or a Foreign
Passport Number and Country of Issuance in the fields provided.
Foreign Passport Number: Enter your Foreign Passport Number in this field. If you do not provide a Foreign Passport
Number, enter N/A in this field, then enter either an Alien Number/USCIS Number or a I-94 Admission Number in the
fields provided.
. If
you did not enter your Foreign Passport Number, enter N/A.
Page 3 of 15Form I-9 Instructions 10/21/2019
Aliens authorized to work must enter one of the following to complete Section 1:
Your employer may not ask you to present the document from which you supplied this information.
• Both you and your preparer(s) and/or translator(s) must complete the appropriate areas of Section 1, and then sign
Section 1. If Section 1 was completed on a form obtained from the USCIS website, the form must be printed to sign
these fields. You and your preparer(s) and/or translator(s) also should review the instructions for Completing the
Preparer and/or Translator Certification below.
• If the employee is a minor (individual under 18) who cannot present an identity document, the employee's parent or
legal guardian can complete Section 1 for the employee and enter “minor under age 18” in the signature field. If Section
1 was completed on a form obtained from the USCIS website, the form must be printed to enter this information. The
minor's parent or legal guardian should review the instructions for Completing the Preparer and/or Translator
Certification below. Refer to the Handbook for Employers: Guidance for Completing Form I-9 (M-274) for more
guidance on completion of Form I-9 for minors. If the minor's employer participates in E-Verify, the employee must
present a list B identity document with a photograph to complete Form I-9.
• If the employee is a person with a disability (who is placed in employment by a nonprofit organization, association or as
part of a rehabilitation program) who cannot present an identity document, the employee's parent, legal guardian or a
representative of the nonprofit organization, association or rehabilitation program can complete Section 1 for the
employee and enter “Special Placement” in this field. If Section 1 was completed on a form obtained from the USCIS
website, the form must be printed to enter this information. The parent, legal guardian or representative of the nonprofit
organization, association or rehabilitation program completing Section 1 for the employee should review the
instructions for Completing the Preparer and/or Translator Certification below. Refer to the Handbook for Employers:
Guidance for Completing Form I-9 (M-274) for more guidance on completion of Form I-9 for certain employees with
disabilities.
If you used a preparer, translator, and other individual to assist you in completing Form I-9:
Signature of Employee: After completing Section 1, sign your name in this field. If you used a form obtained from the
USCIS website, you must print the form to sign your name in this field. By signing this form, you attest under penalty of
perjury (28 U.S.C. § 1746) that the information you provided, along with the citizenship or immigration status you selected,
and all information and documentation you provide to your employer, is complete, true and correct, and you are aware that you
may face severe penalties provided by law and may be subject to criminal prosecution for knowingly and willfully making
false statements or using false documentation when completing this form. Further, falsely attesting to U.S. citizenship may
subject employees to penalties, removal proceedings and may adversely affect an employee's ability to seek future immigration
benefits. If you cannot sign your name, you may place a mark in this field to indicate your signature. Employees who use a
preparer or translator to help them complete the form must still sign or place a mark in the Signature of Employee field on the
printed form.
Today's Date: Enter the date you signed Section 1 in this field. Do not backdate this field. Enter the date as a 2-digit month,
2-digit day and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014. A preparer or translator who
assists the employee in completing Section 1 may enter the date the employee signed or made a mark to sign Section 1 in this
field. Parents or legal guardians assisting minors (individuals under age 18) and parents, legal guardians or representatives of a
nonprofit organization, association or rehabilitation program assisting certain employees with disabilities must enter the date
they completed Section 1 for the employee.
If you did not use a preparer or translator to assist you in completing Section 1, you, the employee, must check the box marked
I did not use a Preparer or Translator. If you check this box, leave the rest of the fields in this area blank.
If one or more preparers and/or translators assist the employee in completing the form using a computer, the preparer and/or
translator must check the box marked “A preparer(s) and/or translator(s) assisted the employee in completing Section 1”,
then select the number of Certification areas needed from the dropdown provided. Any additional Certification areas generated
will result in an additional page. The Form I-9 Supplement
, Section 1 Preparer and/or Translator Certification, can be separately
downloaded from the USCIS Form I-9 webpage, which provides additional Certification areas for those completing Form I-9
using a computer who need more Certification areas than the 5 provided or those who are completing Form I-9 on paper. The
first preparer and/or translator must complete all the fields in the Certification area on the same page the employee has signed.
There is no limit to the number of preparers and/or translators an employee can use, but each additional preparer and/or
translator must complete and sign a separate Certification area. Ensure the employee's last name, first name and middle initial
are entered at the top of any additional pages. The employer must ensure that any additional pages are retained with the
employee's completed Form I-9.
Page 4 of 15Form I-9 Instructions 10/21/2019
Signature of Preparer or Translator: Any person who helped to prepare or translate Section 1of Form I-9 must sign his or
her name in this field. If you used a form obtained from the USCIS website, you must print the form to sign your name in this
field. The Preparer and/or Translator Certification must also be completed if “Individual under Age 18” or “Special Placement”
is entered in lieu of the employee’s signature in Section 1.
Form I-9 Instructions 10/21/2019
Today's Date: The person who signs the Preparer and/or Translator Certification must enter the date he or she signs in this
field on the printed form. Do not backdate this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/
yyyy). For example, enter January 8, 2014 as 01/08/2014.
Last Name Enter the full legal last name of the person who helped the employee in preparing or translating
Section 1 in this field. The last name is also the family name or surname. If the preparer or translator has two last names or a
hyphenated last name, include both names in this field.
First Name ( ): Enter the full legal first name of the person who helped the employee in preparing or translating
Section 1 in this field. The first name is also the given name.
Address ( ): Enter the street name and number of the current address of the residence of the person
who helped the employee in preparing or translating Section 1 in this field. Addresses for residences in Canada or Mexico may
be entered in this field. If the residence does not have a physical address, enter a description of the location of the residence,
such as “3 miles southwest of Anytown post office near water tower.” If the residence is an apartment, enter the apartment
number in this field.
City or Town: Enter the city, town or village of the residence of the person who helped the employee in preparing or
translating Section 1 in this field. If the residence is not located in a city, town or village, enter the name of the county,
township, reservation, etc., in this field. If the residence is in Canada, enter the city and province in this field. If the residence is
in Mexico, enter the city and state in this field.
State: Enter the abbreviation of the state, territory or country of the preparer or translator’s residence in this field.
ZIP Code: Enter the 5-digit ZIP code of the residence of the person who helped the employee in preparing or translating
Section 1 in this field. If the preparer or translator's residence is in Canada or Mexico, enter the 5- or 6-digit postal code.
Within 3 business days of starting work for pay, you must present to your employer documentation that establishes your
identity and employment authorization. For example, if you begin employment on Monday, you must present documentation
on or before Thursday of that week. However, if you were hired to work for less than 3 business days, you must present
documentation no later than the first day of employment.
Choose which unexpired document(s) to present to your employer from the Lists of Acceptable Documents. An employer
cannot specify which document(s) you may present from the Lists of Acceptable Documents. You may present either one
selection from List A or a combination of one selection from List B and one selection from List C. Some List A documents,
which show both identity and employment authorization, are combination documents that must be presented together to be
considered a List A document: for example, the foreign passport together with a Form I-94 containing an endorsement of the
alien’s nonimmigrant status and employment authorization with a specific employer incident to such status. List B documents
show identity only and List C documents show employment authorization only. If your employer participates in E-Verify and
you present a List B document, the document must contain a photograph. If you present acceptable List A documentation, you
should not be asked to present, nor should you provide, List B and List C documentation. If you present acceptable List B and
List C documentation, you should not be asked to present, nor should you provide, List A documentation. If you are unable to
present a document(s) from these lists, you may be able to present an acceptable receipt. Refer to the Receipts section below.
Your employer must review the document(s) you present to complete Form I-9. If your document(s) reasonably appears to be
genuine and to relate to you, your employer must accept the documents. If your document(s) does not reasonably appear to be
genuine or to relate to you, your employer must reject it and provide you with an opportunity to present other documents from
the Lists of Acceptable Documents. Your employer may choose to make copies of your document(s), but must return the
original(s) to you. Your employer must review your documents in your physical presence.
Page 5 of 15
Your employer will complete the other parts of this form, as well as review your entries in Section 1. Your employer may ask
you to correct any errors found. Your employer is responsible for ensuring all parts of Form I-9 are properly completed and is
subject to penalties under federal law if the form is not completed correctly.
Minors (individuals under age 18) and certain employees with disabilities whose parent, legal guardian or representative
completed Section 1 for the employee are only required to present an employment authorization document from List C. Refer to
the Handbook for Employers: Guidance for Completing Form I-9 (M-274)
for more guidance on minors and certain individuals
with disabilities.
If you do not have unexpired documentation from the Lists of Acceptable Documents, you may be able to present a receipt(s) in
lieu of an acceptable document(s). New employees who choose to present a receipt(s) must do so within three business days of
their first day of employment. If your employer is reverifying your employment authorization, and you choose to present a
receipt for reverification, you must present the receipt by the date your employment authorization expires. Receipts are not
acceptable if employment lasts fewer than three business days.
There are three types of acceptable receipts:
Receipts showing that you have applied for an initial grant of employment authorization, or for renewal of your expiring or
expired employment authorization, are not acceptable.
1. A receipt showing that you have applied to replace a document that was lost, stolen or damaged. You must present the
actual document within 90 days from the date of hire or, in the case of reverification, within 90 days from the date your
original employment authorization expires.
2. The arrival portion of Form I-94/I-94A containing a temporary I-551 stamp and a photograph of the individual. You must
present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporary I-551 stamp, or, if there is
no expiration date, within 1 year from the date of admission.
3. The departure portion of Form I-94/I-94A with a refugee admission stamp. You must present an unexpired Employment
Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social Security Card
within 90 days from the date of hire or, in the case of reverification, within 90 days from the date your original employment
authorization expires.
You, the employer, must ensure that all parts of Form I-9 are properly completed and may be subject to penalties under federal
law if the form is not completed correctly. Section 1 must be completed no later than the employee’s first day of employment.
You may not ask an individual to complete Section 1 before he or she has accepted a job offer. Before completing Section 2,
you should review Section 1 to ensure the employee completed it properly. If you find any errors in Section 1, have the
employee make corrections, as necessary and initial and date any corrections made.
You may designate an authorized representative to act on your behalf to complete Section 2. An authorized representative can
be any person you designate to complete and sign Form I-9 on your behalf. You are liable for any violations in connection with
the form or the verification process, including any violations of the employer sanctions laws committed by the person
designated to act on your behalf.
You or your authorized representative must complete Section 2 by examining evidence of identity and employment
authorization within 3 business days of the employee’s first day of employment. For example, if an employee begins
employment on Monday, you must review the employee's documentation and complete Section 2 on or before Thursday of that
week. However, if you hire an individual for less than 3 business days, Section 2 must be completed no later than the first day
of employment.
Completing Section 2: Employer or Authorized Representative Review and Verification
Page 6 of 15Form I-9 Instructions 10/21/2019
This area, titled, “Employee Info from Section 1” contains fields to enter the employee's last name, first name, middle initial
exactly as he or she entered them in Section 1. This area also includes a Citizenship/Immigration Status field to enter the
number of the citizenship or immigration status checkbox the employee selected in Section 1. These fields help to ensure that
the two pages of an employee's Form I-9 remain together. When completing Section 2 using a computer, the number entered in
the Citizenship/Immigration Status field provides drop-downs that directly relate to the employee's selected citizenship or
immigration status.
You, the employer or authorized representative, must physically examine, in the employee's physical presence, the unexpired
document(s) the employee presents from the Lists of Acceptable Documents to complete the Document fields in Section 2.
You cannot specify which document(s) an employee may present from these lists. If you discriminate in the Form I-9 process
based on an individual's citizenship status, immigration status, or national origin, you may be in violation of the law and subject
to sanctions such as civil penalties and be required to pay back pay to discrimination victims. A document is acceptable as long
as it reasonably appears to be genuine and to relate to the person presenting it. Employees must present one selection from List
A or a combination of one selection from List B and one selection from List C.
List A documents show both identity and employment authorization. Some List A documents are combination documents that
must be presented together to be considered a List A document, such as a foreign passport together with a Form I-94 containing
an endorsement of the alien’s nonimmigrant status.
If an employee presents a receipt for the application to replace a lost, stolen or damaged document, the employee must present
the replacement document to you within 90 days of the first day of work for pay, or in the case of reverification, within 90 days
of the date the employee's employment authorization expired. Enter the word “Receipt” followed by the title of the receipt in
Section 2 under the list that relates to the receipt.
When your employee presents the replacement document, draw a line through the receipt, then enter the information from the
new document into Section 2. Other receipts may be valid for longer or shorter periods, such as the arrival portion of Form I-94/
I-94A containing a temporary I-551 stamp and a photograph of the individual, which is valid until the expiration date of the
temporary I-551 stamp or, if there is no expiration date, valid for one year from the date of admission.
Ensure that each document is an unexpired, original (no photocopies, except for certified copies of birth certificates) document.
Certain employees may present an expired employment authorization document, which may be considered unexpired, if the
employee's employment authorization has been extended by regulation or a Federal Register Notice. Refer to the
Handbook for
Employers: Guidance for Completing Form I-9 (M-274) or I-9 Central for more guidance on these special situations.
Refer to the M-274 for guidance on how to handle special situations, such as students (who may present additional documents
not specified on the Lists) and H-1B and H-2A nonimmigrants changing employers.
Minors (individuals under age 18) and certain employees with disabilities whose parent, legal guardian or representative
completed Section 1 for the employee are only required to present an employment authorization document from List C. Refer to
the M-274 for more guidance on minors and certain persons with disabilities. If the minor's employer participates in E-Verify,
the minor employee also must present a List B identity document with a photograph to complete Form I-9.
You must return original document(s) to the employee, but may make photocopies of the document(s) reviewed. Photocopying
documents is voluntary unless you participate in E-Verify. E-Verify employers are only required to photocopy certain
documents. If you are an E-Verify employer who chooses to photocopy documents other than those you are required to
photocopy, you should apply this policy consistently with respect to Form I-9 completion for all employees. For more
information on the types of documents that an employer must photocopy if the employer uses E-Verify, visit E-Verify’s website
at www.everify.gov
. For non-E-Verify employers, if photocopies are made, they should be made consistently for ALL new
hires and reverified employees.
Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or another federal government
agency. You must always complete Section 2 by reviewing original documentation, even if you photocopy an employee’s
document(s) after reviewing the documentation. Making photocopies of an employee’s document(s) cannot take the place of
completing Form I-9. You are still responsible for completing and retaining Form I-9.
Page 7 of 15Form I-9 Instructions 10/21/2019
List A - Identity and Employment Authorization: If the employee presented an acceptable document(s) from List A or an
acceptable receipt for a List A document, enter the document(s) information in this column. If the employee presented a List A
document that consists of a combination of documents, enter information from each document in that combination in a separate
area under List A as described below. All documents must be unexpired. If you enter document information in the List A
column, you should not enter document information or N/A in the List B or List C columns. If you complete Section 2 using a
computer, a selection in List A will fill all the fields in the Lists B and C columns with N/A.
Document Title: If the employee presented a document from List A, enter the title of the List A document or receipt in
this field. The abbreviations provided are available in the dropdown when the form is completed on a computer. When
completing the form on paper, you may choose to use these abbreviations or any other common abbreviation to enter the
document title or issuing authority. If the employee presented a combination of documents, use the second and third
Document Title fields as necessary.
Full name of List A Document
Abbreviations
U.S. Passport U.S. Passport
U.S. Passport Card U.S. Passport Card
Permanent Resident Card (Form I-551) Perm. Resident Card (Form I-551)
Alien Registration Receipt Card (Form I-551)
Foreign passport containing a temporary I-551 stamp
1. Foreign Passport
2. Temporary I-551 Stamp
Foreign passport containing a temporary I-551 printed notation on a
machine-readable immigrant visa (MRIV)
Employment Authorization Document (Form I-766) Employment Auth. Document (Form I-766)
For a nonimmigrant alien authorized to work for a specific employer
because of his or her status, a foreign passport
with Form I/94/I-94A that contains an endorsement of the alien's
nonimmigrant status
1. Foreign Passport, work-authorized non-immigrant
2. Form I-94/I94A
3. Form I-20 or Form DS-2019
Note: In limited circumstances, certain J-1 students
may be required to present a letter from their
Responsible Officer in order to work. Enter the
document title, issuing authority, document number
and expiration date from this document in the
Additional Information field.
Passport from the Federated States of Micronesia (FSM)
with Form I-94/I-94A
1. FSM Passport with Form I-94
2. Form I-94/I94A
Passport from the Republic of the Marshall Islands (RMI)
with Form I-94/I94A
1. RMI Passport with Form I-94
2. Form I-94/I94A
Receipt: The arrival portion of Form I-94/I-94A containing a temporary
I-551 stamp and photograph
Receipt: Form I-94/I-94A w/I-551 stamp, photo
Receipt: The departure portion of Form I-94/I-94A
with an unexpired refugee admission stamp
Receipt: Form I-94/I-94A w/refugee stamp
Receipt for an application to replace a lost, stolen or damaged
Permanent Resident Card (Form I-551)
Receipt replacement Perm. Res. Card
(Form I-551)
Receipt for an application to replace a lost, stolen or damaged
Employment Authorization Document (Form I-766)
Receipt replacement EAD (Form I-766)
Receipt for an application to replace a lost, stolen or damaged foreign
passport with Form I-94/I-94A that contains an endorsement of the
alien's nonimmigrant status
1. Receipt:
work-authorized nonimmigrant
2. Receipt: Replacement Form I-94/I-94A
Receipt for an application to replace a lost, stolen or damaged
passport from the Federated States of Micronesia with Form I-94/I-94A
1. Receipt: Replacement FSM Passport with Form I-94
2. Receipt: Replacement Form I-94/I-94A
Receipt for an application to replace a lost, stolen or damaged
passport from the Republic of the Marshall Islands with Form I-94/
I-94A
1. Receipt: Replacement RMI Passport with Form I-94
2. Receipt: Replacement Form I-94/I-94A
Issuing Authority: Enter the issuing authority of the List A document or receipt. The issuing authority is the specific
entity that issued the document. If the employee presented a combination of documents, use the second and third Issuing
Authority fields as necessary.
Page 8 of 15Form I-9 Instructions 10/21/2019
Document Number: Enter the document number, if any, of the List A document or receipt presented. If the document
does not contain a number, enter N/A in this field. If the employee presented a combination of documents, use the second
and third Document Number fields as necessary. If the document presented was a Form I-20 or DS-2019, enter the
Student and Exchange Visitor Information System (SEVIS) number in the third Document Number field exactly as it
appears on the Form I-20 or the DS-2019.
Expiration Date ( ) ( ): Enter the expiration date, if any, of the List A document. The document is not
acceptable if it has already expired. If the document does not contain an expiration date, enter N/A in this field. If the
document uses text rather than a date to indicate when it expires, enter the text as shown on the document, such as
“D/S” (which means, “duration of status”). For a receipt, enter the expiration date of the receipt validity period as
described above. If the employee presented a combination of documents, use the second and third Expiration Date fields
as necessary. If the document presented was a Form I-20 or DS-2019, enter the program end date here.
Document Title:
the document title or
issuing authority.
Full name of List B Document Abbreviations
Driver's license issued by a State or outlying possession of the United
States
Driver's license issued by state/territory
ID card issued by a State or outlying possession of the
United States
ID card issued by state/territory
ID card issued by federal, state, or local government agencies or
entities (Note: This selection does not include the driver's license or ID
card issued by a State or outlying possession of the United States as
described in B1 of the List of Acceptable Documents.)
Government ID
School ID card with photograph School ID
Voter's registration card Voter registration card
U.S. Military card U.S. Military card
U.S. Military draft record U.S. Military draft record
Military dependent's ID card Military dependent's ID card
U.S. Coast Guard Merchant Mariner Card USCG Merchant Mariner card
Native American tribal document Native American tribal document
Driver's license issued by a Canadian government authority Canadian driver's license
School record (for persons under age 18 who are unable to present a
document listed above)
School record (under age 18)
Report card (for persons under age 18 who are unable to present a
document listed above)
Report card (under age 18)
Clinic record (for persons under age 18 who are unable to present a
document listed above)
Clinic record (under age 18)
Doctor record (for persons under age 18 who are unable to present a
document listed above)
Doctor record (under age 18)
Hospital record (for persons under age 18 who are unable to present a
document listed above)
Hospital record (under age 18)
Day-care record (for persons under age 18 who are unable to present
a document listed above)
Day-care record (under age 18)
Nursery school record (for persons under age 18 who are unable to
present a document listed above)
Nursery school record (under age 18)
Page 9 of 15Form I-9 Instructions 10/21/2019
List B - Identity: If the employee presented an acceptable document from List B or an acceptable receipt for the application to
replace a lost, stolen, or destroyed List B document, enter the document information in this column. If a parent or legal guardian
attested to the identity of an employee who is an individual under age 18 or certain employees with disabilities
in Section 1,
enter either "Individual under age 18" or "Special Placement" in this field. Refer to the
Handbook for Employers: Guidance for
Completing Form I-9 (M-274)
for more guidance on individuals under age 18 and certain person with disabilities.
If you enter document information in the List B column, you must also enter document information in the List C column. If an
employee presents acceptable List B and List C documents, do not ask the employees to present a List A document. If you enter
document information in List B, you should not enter document information or N/A in List A. If you complete Section 2 using a
computer, a selection in List B will fill all the fields in the List A column with N/A.
Full name of List B Document Abbreviations
Individual under age 18 endorsement by parent or guardian Individual under Age 18
Special placement endorsement for persons with disabilities Special Placement
Receipt for the application to replace a lost, stolen or damaged Driver's
License issued by a State or outlying possession of the United States
Receipt: Replacement driver's license
Receipt for the application to replace a lost, stolen or damaged ID card
issued by a State or outlying possession of the United States
Receipt: Replacement ID card
Receipt for the application to replace a lost, stolen or damaged ID card
issued by federal, state, or local government agencies or entities
Receipt: Replacement Gov't ID
Receipt for the application to replace a lost, stolen or damaged School
ID card with photograph
Receipt: Replacement School ID
Receipt for the application to replace a lost, stolen or damaged Voter's
registration card
Receipt: Replacement Voter reg. card
Receipt for the application to replace a lost, stolen or damaged U.S.
Military card
Receipt: Replacement U.S. Military card
Receipt for the application to replace a lost, stolen or damaged Military
dependent's ID card
Receipt: Replacement U.S. Military dep. card
Receipt for the application to replace a lost, stolen or damaged U.S.
Military draft record
Receipt: Replacement Military draft
record
Receipt for the application to replace a lost, stolen or damaged U.S.
Coast Guard Merchant Mariner Card
Receipt: Replacement Merchant Mariner card
Receipt for the application to replace a lost, stolen or damaged Driver's
license issued by a Canadian government authority
Receipt: Replacement Canadian DL
Receipt for the application to replace a lost, stolen or damaged Native
American tribal document
Receipt: Replacement Native American
tribal doc
Receipt for the application to replace a lost, stolen or damaged School
record (for persons under age 18 who are unable to present a
document listed above)
Receipt: Replacement School record
(under age 18)
Receipt for the application to replace a lost, stolen or damaged Report
card (for persons under age 18 who are unable to present a document
listed above)
Receipt: Replacement Report card
(under age 18)
Receipt for the application to replace a lost, stolen or damaged Clinic
record (for persons under age 18 who are unable to present a
document listed above)
Receipt: Replacement Clinic record
(under age 18)
Receipt for the application to replace a lost, stolen or damaged Doctor
record (for persons under age 18 who are unable to present a
document listed above)
Receipt: Replacement Doctor record
(under age 18)
Receipt for the application to replace a lost, stolen or damaged
Hospital record (for persons under age 18 who are unable to present a
document listed above)
Receipt: Replacement Hospital record
(under age 18)
Receipt for the application to replace a lost, stolen or damaged Day-
care record (for persons under age 18 who
are unable to present a document listed above)
Receipt: Replacement Day-care record
(under age 18)
Receipt for the application to replace a lost, stolen or damaged
Nursery school record (for persons under age 18 who are unable to
present a document listed above)
Receipt: Replacement Nursery school record (under
age 18)
Issuing Authority: Enter the issuing authority of the List B document or receipt. The issuing authority is the entity that
issued the document. If the employee presented a document that is issued by a state agency, include the state as part of
the issuing authority.
Document Number: Enter the document number, if any, of the List B document or receipt exactly as it appears on the
document. If the document does not contain a number, enter N/A in this field.
Page 10 of 15Form I-9 Instructions 10/21/2019
Full name of List C Document Abbreviations
Social Security Account Number card without restrictions (Unrestricted) Social Security Card
Certification of Birth Abroad (Form FS-545) Form FS-545
Certification of Report of Birth (Form DS-1350) Form DS-1350
Consular Report of Birth Abroad (Form FS-240) Form FS-240
Original or certified copy of a U.S. birth certificate bearing an official seal Birth Certificate
Native American tribal document Native American tribal document
U.S. Citizen ID Card (Form I-197) Form I-197
Identification Card for use of Resident Citizen in the United States (Form
I-179)
Form I-179
Employment Auth. document (DHS) List C #7
Receipt for the application to replace a lost, stolen or damaged Social
Security Account Number Card without restrictions
Receipt: Replacement Unrestricted SS Card
Receipt for the application to replace a lost, stolen or damaged Original or
certified copy of a U.S. birth certificate bearing an official seal
Receipt: Replacement Birth Certificate
Receipt for the application to replace a lost, stolen or damaged Native
American Tribal Document
Receipt: Replacement Native American Tribal Doc.
Receipt: Replacement Employment Auth. Doc. (DHS)
Document Title: If the employee presented a document from List C, enter the title of the List C document or receipt in
this field. The abbreviations provided are available in the dropdown when the form is completed on a computer. When
completing the form on paper, you may choose to use these abbreviations or any other common abbreviations to document
the document title or issuing authority. If you are completing the form on a computer, and you select an Employment
authorization document issued by DHS, the field will populate with List C #7 and provide a space for you to enter a
description of the documentation the employee presented. Refer to the M-274 for guidance on entering List C #7
documentation.
List C - Employment Authorization: If the employee presented an acceptable document from List C, or an acceptable
receipt for the application to replace a lost, stolen, or destroyed List C document, enter the document information in this
column. If you enter document information in the List C column, you must also enter document information in the List B
column. If an employee presents acceptable List B and List C documents, do not ask the employee to present a list A document.
If you enter document information in List C, you should not enter document information or N/A in List A. If you complete
Section 2 using a computer, a selection in List C will fill all the fields in the List A column with N/A.
Additional Information: Use this space to notate any additional information required for Form I-9 such as:
• Employment authorization extensions for Temporary Protected Status beneficiaries, F-1 OPT STEM students, CAP-
GAP, H-1B and H-2A employees continuing employment with the same employer or changing employers, and other
nonimmigrant categories that may receive extensions of stay
• Additional document(s) that certain nonimmigrant employees may present
• Discrepancies that E-Verify employers must notate when participating in the IMAGE program
• Employee termination dates and form retention dates
• E-Verify case number, which may also be entered in the margin or attached as a separate sheet per E-Verify
requirements and your chosen business process
• Any other comments or notations necessary for the employer's business process
Page 11 of 15Form I-9 Instructions 10/21/2019
You may leave this field blank if the employee's circumstances do not require additional notations.
Signature of Employer or Authorized Representative: Review the form for accuracy and completeness. The person who
physically examines the employee's original document(s) and completes Section 2 must sign his or her name in this field. If you
used a form obtained from the USCIS website, you must print the form to sign your name in this field. By signing Section 2,
you attest under penalty of perjury (28 U.S.C. § 1746) that you have physically examined the documents presented by the
employee, the document(s) reasonably appear to be genuine and to relate to the employee named, that to the best of your
knowledge the employee is authorized to work in the United States, that the information you entered in Section 2 is complete,
true and correct to the best of your knowledge, and that you are aware that you may face severe penalties provided by law and
may be subject to criminal prosecution for knowingly and willfully making false statements or knowingly accepting false
documentation when completing this form.
Today's Date: The person who signs Section 2 must enter the date he or she signed Section 2 in this field. Do not backdate this
field. If you used a form obtained from the USCIS website, you must print the form to write the date in this field. Enter the date
as a 2-digit month, 2-digit day and 4-digit year (mm/dd/yyyy). For example, enter January 8, 2014 as 01/08/2014.
Title of Employer or Authorized Representative: Enter the title, position or role of the person who physically examines the
employee's original document(s), completes and signs Section 2.
Last Name of the Employer or Authorized Representative: Enter the full legal last name of the person who physically
examines the employee’s original documents, completes and signs Section 2. Last name refers to family name or surname. If
the person has two last names or a hyphenated last name, include both names in this field.
First Name of the Employer or Authorized Representative: Enter the full legal first name of the person who physically
examines the employee’s original documents, completes, and signs Section 2. First name refers to the given name.
.
Employer’s Business or Organization Address ( ): Enter an actual, physical address of the
employer. If your company has multiple locations, use the most appropriate address that identifies the location of the employer.
Do not provide a P.O. Box address.
City or Town: Enter the city or town for the employer’s business or organization address. If the location is not a city or town,
you may enter the name of the village, county, township, reservation, etc, that applies.
State: Enter the two-character abbreviation of the state for the employer’s business or organization address.
ZIP Code: Enter the 5-digit ZIP code for the employer’s business or organization address.
Completing Section 3: Reverification and Rehires
Section 3 applies to both reverification and rehires. When completing this section, you must also complete the Last Name, First
Name and Middle Initial fields in the Employee Info from Section 1 area at the top of Section 2, leaving the Citizenship/
Immigration Status field blank. When completing Section 3 in either a reverification or rehire situation, if the employee’s name
has changed, record the new name in Block A.
Reverification
Reverification in Section 3 must be completed prior to the earlier of:
• The expiration date, if any, of the employment authorization stated in Section 1, or
• The expiration date, if any, of the List A or List C employment authorization document recorded in Section 2
(with some exceptions listed below).
Some employees may have entered “N/A” in the expiration date field in Section 1 if they are aliens whose employment
authorization does not expire, e.g. asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the
Marshall Islands, or Palau. Reverification does not apply for such employees unless they choose to present evidence of
employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766,
Employment Authorization Document.
You should not reverify U.S. citizens and noncitizen nationals, or lawful permanent residents (including conditional residents)
who presented a Permanent Resident Card (Form I-551). Reverification does not apply to List B documents.
Page 12 of 15Form I-9 Instructions 10/21/2019
Employee's First Day of Employment: Enter the employee's first day of employment as a 2-digit month, 2-digit day and
4-digit year (mm/dd/yyyy).
• If the employee remains employment authorized as indicated on the previously executed Form I-9, the employee does
not need to provide any additional documentation. Provide in Section 3 the employee’s rehire date, any name changes if
applicable, and sign and date the form.
• If the previously executed Form I-9 indicates that the employee’s employment authorization from Section 1 or
employment authorization documentation from Section 2 that is subject to reverification has expired, then
reverification of employment authorization is required in Section 3 in addition to providing the rehire date. If the
previously executed Form I-9 is not the current version of the form, you must complete Section 3 on the current
version of the form.
• If you already used Section 3 of the employee’s previously executed Form I-9, but are rehiring the employee within
three years of the original execution of Form I-9, you may complete Section 3 on a new Form I-9 and attach it to the
previously executed form.
If you rehire an employee within three years from the date that the Form I-9 was previously executed, you may either rely on
the employee’s previously executed Form I-9 or complete a new Form I-9.
If you choose to rely on a previously completed Form I-9, follow these guidelines.
Employees rehired after three years of original execution of the Form I-9 must complete a new Form I-9.
Complete each block in Section 3 as follows:
Block A - New Name: If an employee who is being reverified or rehired has also changed his or her name since originally
completing Section 1 of this form, complete this block with the employee’s new name. Enter only the part of the name that has
changed, for example: if the employee changed only his or her last name, enter the last name in the Last Name field in this
Block, then enter N/A in the First Name and Middle Initial fields. If the employee has not changed his or her name, enter N/A in
each field of Block A.
Block B - Date of Rehire: Complete this block if you are rehiring an employee within three years of the date Form I-9 was
originally executed. Enter the date of rehire in this field. Enter N/A in this field if the employee is not being rehired.
Block C - Complete this block if you are reverifying expiring or expired employment authorization or employment
authorization documentation of a current or rehired employee. Enter the information from the List A or List C document(s) (or
receipt) that the employee presented to reverify his or her employment authorization. All documents must be unexpired.
Document Title: Enter the title of the List A or C document (or receipt) the employee has presented to show continuing
employment authorization in this field.
Document Number: Enter the document number, if any, of the document you entered in the Document Title field
exactly as it appears on the document. Enter N/A if the document does not have a number.
Expiration Date ( ) ( ): Enter the expiration date, if any, of the document you entered in the Document
Title field as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). If the document does not contain an expiration
date, enter N/A in this field.
Page 13 of 15Form I-9 Instructions 10/21/2019
Rehires
For reverification, an employee must present an unexpired document(s) (or a receipt) from either List A or List C showing he or
she is still authorized to work. You CANNOT require the employee to present a particular document from List A or List C. The
employee is also not required to show the same type of document that he or she presented previously. See specific instructions
on how to complete Section 3 below.
Signature of Employer or Authorized Representative: The person who completes Section 3 must sign in this field. If you
used a form obtained from the USCIS website, you must print Section 3 of the form to sign your name in this field. By signing
Section 3, you attest under penalty of perjury (28 U.S.C.
1746) that you have examined the documents presented by the
employee, that the document(s) reasonably appear to be genuine and to relate to the employee named, that to the best of your
knowledge the employee is authorized to work in the United States, that the information you entered in Section 3 is complete,
true and correct to the best of your knowledge, and that you are aware that you may face severe penalties provided by law and
may be subject to criminal prosecution for knowingly and willfully making false statements or knowingly accepting false
documentation when completing this form.
For additional guidance about Form I-9, employers and employees should refer to the Handbook for Employers: Guidance for
Completing Form I-9 (M-274) or USCIS’ Form I-9 website at https://www.uscis.gov/i-9-central
.
You can also obtain information about Form I-9 by e-mailing USCIS at I-9Central@dhs.gov
, or by calling 1-888-464-4218 or
1-877-875-6028 (TTY).
You may download and obtain the English and Spanish versions of Form I-9, the Handbook for Employers, or the instructions
to Form I-9 from the USCIS website at https://www.uscis.gov/i-9
. To complete Form I-9 on a computer, you will need the latest
version of Adobe Reader, which can be downloaded for free at http://get.adobe.com/reader/
. You may order paper forms at
https://www.uscis.gov/forms/forms-by-mail
by contacting the USCIS Contact Center at 1-800-375-5283 or 1-800-767-1833
(TTY).
at or by contacting E-Verify at .
Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781 or
1-877-875-6028 (TTY).
USCIS Forms and Information
Page 14 of 15Form I-9 Instructions 10/21/2019
Employers may photocopy or print blank Forms I-9 for future use. All pages of the instructions and Lists of Acceptable
Documents must be available, either in print or electronically, to all employees completing this form. Employers must retain
each employee's completed Form I-9 for as long as the individual works for the employer and for a specified period after
employment has ended. Employers are required to retain the pages of the form on which the employee and employer entered
data. If copies of documentation presented by the employee are made, those copies must also be retained. Once the individual's
employment ends, the employer must retain this form and attachments for either 3 years after the date of hire (i.e., first day of
work for pay) or 1 year after the date employment ended, whichever is later. In the case of recruiters or referrers for a fee (only
applicable to those that are agricultural associations, agricultural employers, or farm labor contractors), the retention period is 3
years after the date of hire (i.e., first day of work for pay).
Forms I-9 obtained from the USCIS website that are not printed and signed manually (by hand) are not considered complete. In
the event of an inspection, retaining incomplete forms may make you subject to fines and penalties associated with incomplete
forms.
Employers should ensure that information employees provide on Form I-9 is used only for Form I-9 purposes. Completed
Forms I-9 and all accompanying documents should be stored in a safe, secure location.
Form I-9 may be generated, signed, and retained electronically, in compliance with Department of Homeland Security
regulations at 8 CFR 274a.2.
Photocopying Blank and Completed Forms I-9 and Retaining Completed Forms I-9
There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be
retained by the employer and made available for inspection by U.S. Government officials as specified in the “
DHS Privacy
Notice” below.
What is the Filing Fee?
Today's Date: The person who completes Section 3 must enter the date Section 3 was completed and signed in this field. Do
not backdate this field. If you used a form obtained from the USCIS website, you must print Section 3 of the form to enter the
date in this field. Enter the date as a 2-digit month, 2-digit day, and 4-digit year (mm/dd/yyyy). For example, enter January 8,
2014 as 01/08/2014.
Name of Employer or Authorized Representative: The person who completed, signed and dated Section 3 must enter his
or her name in this field.
An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. The public reporting burden for this collection of
information is estimated at 35 minutes per response, when completing the form manually, and 26 minutes per response when
using a computer to aid in completion of the form, including the time for reviewing instructions and completing and retaining
the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office
of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do not mail your
completed Form I-9 to this address.
Paperwork Reduction Act
Page 15 of 15Form I-9 Instructions 10/21/2019
DHS Privacy Notice
AUTHORITIES: The information requested on this form, and the associated documents, are collected under the Immigration
Reform and Control Act of 1986, Pub. L. 99-603 (8 USC 1324a).
PURPOSE: The primary purpose for providing the requested information on this form is for employers to verify your identity
and employment authorization. Consistent with the requirements of the Immigration Reform and Control Act of 1986,
employers use the Form I-9 to document the verification of the identity and employment authorization for new employees to
prevent the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.
This form is completed by both the employer and employee, and is ultimately retained by the employer.
DISCLOSURE: The information you provide is voluntary. However, failure to provide the requested information, including
your Social Security number (if applicable), and any requested evidence, may result in termination of employment. Failure of
the employer to ensure proper completion of this form may result in the imposition of civil or criminal penalties against the
employer. In addition, knowingly employing individuals who are not authorized to work in the United States may subject the
employer to civil and/or criminal penalties.
ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of an
individual to work in the United States. The employer must retain this completed form and make it available for inspection by
authorized officials of the Department of Homeland Security, Department of Labor, and Department of Justice, Civil Rights
Division, Immigrant and Employee Rights Section. DHS may also share this information, as appropriate, for law enforcement
purposes or in the interest of national security.
Backg
round Check Instructions
Using Live Scan on Campus
In accordance with College policy, all employees, interns, and volunteers must complete a Level
II background screening once they have been selected or scheduled for an assignment.
• Payment
for the fingerprinting to acquire a criminal background check is paid by the employee
via payroll deduction. An authorization for deduction form will be provided, and Human
Resources will process the set up for such deduction.
• Volunt
eers and interns in non-paid assignments will be responsible to make a direct payment to
the College’s Cashier office and produce a receipt before the fingerprinting appointment is
arranged.
•
The College’s live scan equipment to acquire fingerprints is located at the Pensacola campus,
Public Safety/College Police Department entrance area, Building 5. The department may be
reached at 850-484-2500, or ext. 2500 on campus. To ensure staff who operate the live
scan equipment are available to perform the checks, it is recommended to arrive at Public
Safety by 3:00 p.m. for the fingerprinting process.
•
All parties who are printed by the College’s live scan are required to complete a VECHS Waiver
Form which will be provided by Human Resources, or available at the Public Safety/College
Police Department. Completed VECHS Waiver forms will be maintained by the Human
Resources Department for each individual.
Please refer
ence the Board of Trustees' Policy, 6Hx20.1.036, for further information:
PSC Criminal Background Checks/Fingerprinting Policy
Questio
ns may be directed to:
Tammy R
. Henderson
Director, Human Resources
1000 College Blvd.
Pensacola, FL 32504-8998
Office Phone: 850-484-1766
thenderson@pensacolastate.edu
Rev. 04/2019
Employee Payroll Deduction Authorization Form
For Criminal Background Check
Name: _______________________________________________________________________
Address: ______________________________________________________________________
City, State, and Zip: ______________________________________________________________
Employee ID: _________________________ Department: _____________________________
Phone Number: _______________________ Email: __________________________________
I understand that pursuant to College policy, it is an employment eligibility requirement for an applicant
to meet the requirements of § 435.04(2), Florida Statutes, related to background investigations. Any
person failing to meet the requirements of the statute will be deemed not qualified to hold employment.
A Florida Department of Law Enforcement (FDLE) approved background check will be conducted on every
successful candidate as a condition of employment, and any person who fails to disclose any adverse
information contained in the background investigation at the time of submitting an employment
application will be disqualified from employment. Please reference the Board of Trustees' Policy,
6Hx20.1.036 for further information.
I authorize a one-time deduction of $37.25 from my paycheck.
Signature:
Date:
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
FOR HUMAN RESOURCES: Code #
Record Updated by: _________________________________ Date: _________________________
Rev. 04/2019
District Board of Trustees of Pensacola State College
District Board of Trustees of Pensacola State College
1000 College Blvd. Pensacola FL, 32504
850-484-1766
850-484-1711
E 17020007
Rev. 04/2019
Department, Program, or Event:
CERT
Rev. 04/2019
EMPLOYERS: RETAIN THIS FORM IN THE EMPLOYEE’S PERSONNEL FILE. DO NOT SEND THIS FORM TO THE FRS, UNLESS REQUESTED.
This form is not an offer of employment or an enrollment form. If hired, a Retirement Choice kit may be mailed to your home with enrollment instructions.
Florida Retirement System (FRS) - Certification Form
Name SSN (last 4 digits)
Agency Name
Previous or Current FRS Employer
Complete Section I if you have never been a member of a State of Florida administered retirement plan.
Complete Section II if you are a current or previous member AND Section III if not retired OR Section IV if retired.
I. I have never been a member of a State of Florida administered retirement plan.
SIGNATURE DATE
II. I was or currently am a member of the following State of Florida administered retirement plan (also complete Section III or IV)
1
FRS Pension Plan (incl. DROP) FRS Investment Plan State University System Optional Retirement Program (SUSORP)
State Community College System Optional Retirement Program (SCCSORP)
Senior Management Service Optional Annuity Program (SMSOAP)
Other
III. I am not retired from any State of Florida administered retirement plan. I understand that if it is later
determined that I was a retiree and was reemployed during the first 6 calendar months after I retired or
after my DROP termination date, or at any time during the 7
th
through the 12
th
calendar months after I
retired or after my DROP termination date, I must repay all unauthorized benefits received (see Section
IV for details), or, if in the Investment Plan, terminate my employment. My employer may also be liable
for repaying any unauthorized benefits I received.
SIGNATURE DATE
Retiree Definition
You are considered
retired if:
1. You have re-
ceived any bene-
fits under the
FRS Pension
Plan, including
DROP (does not
include a with-
drawal of em-
ployee contribu-
tions), or
2. You have taken
any distribution
(including a roll-
over) from the
FRS Investment
Plan, or other
state adminis-
tered retirement
programs offered
by state universi-
ties (SUSORP),
state community
colleges
(SCCSORP),
state govern-
ment for senior
managers
(SMSOAP), or
local govern-
ments for senior
managers.
IV. I am retired from a State of Florida administered retirement plan. My FRS Pension Plan retirement ef-
fective date, DROP termination date, or date I received my first distribution from the FRS Investment
Plan, SUSORP, SCCSORP, SMSOAP, or other plan was ______________________.
Effective July 1, 2017, retirees of the Investment Plan, SUSORP, SCCSORP, and SMSOAP are
eligible for renewed membership in the Investment Plan, SUSORP, or SCCSORP.
I understand that as a Pension Plan retiree:
a. If I am employed by an FRS-participating employer in any type of position
2
during the first 6
calendar months after I retired or after my DROP termination date, my retirement and DROP
status are voided, all retirement and DROP benefits I received must be repaid,
3
and I must reapply
for retirement in order to receive future benefits.
b. If I am reemployed by an FRS-participating employer at any time during the 7
th
through the 12
th
cal-
endar months after I retired or after my DROP termination date, my monthly retirement benefit must
be suspended
4
and any unauthorized benefits received must be repaid.
3
My employer may also
be liable for repaying any unauthorized benefits I received.
I understand that as an Investment Plan, SUSORP, SCCSORP, or SMSOAP retiree:
a. If I am employed by an FRS-participating employer in any type of position
2
during the first 6
calendar months after I retired, I must repay
3
any benefits received or terminate employment for
an additional period to satisfy the 6 calendar month termination requirement.
b. If I am reemployed by an FRS-participating employer at any time during the 7
th
through the 12
th
cal-
endar months after my retirement, I will not be eligible for additional distributions until I terminate
employment or complete 12 calendar months of retirement.
4
SIGNATURE DATE
1
If you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirement plan you were enrolled in when you
terminated FRS-participating employment. You may have a one-time 2
nd
Election to switch FRS retirement plans. Also, alternative retirement programs are available to certain em-
ployees. Contact your employer for deadline and other information.
2
Positions include OPS, temporary, seasonal, substitute teachers, adjunct professors, part-time, full-time, regularly established, etc.
3
Florida law requires a return of all unauthorized Pension Plan benefit payments or Investment Plan distributions received by a member who has violated the FRS termination or
reemployment provisions. Similar provisions apply to unauthorized SUSORP, SCCSORP, or other state-administered plan distributions – contact that plan’s administrator for details.
4
There is one exception to the restrictions on reemployment limitations after retirement. If you are a retired law enforcement officer, you may only be reemployed as a school re-
source officer by an FRS-covered employer during the 7
th
through 12
th
calendar months after your retirement date or after your DROP termination date and receive both your salary
and retirement benefits.
STOP HERE
LOYALTY OATH
(As required by Chapter 876.05 Acts of 1967)
I, ________________________, a citizen of the State of Florida and of the United States of America,
and being employed by or an officer of the District Board of Trustees of Pensacola State College, and
a recipient of public funds as such employee or officer, do hereby solemnly swear or affirm that I will
support the Constitution of the United States and the State of Florida.
Signature Date
STATE OF FLORIDA
COUNTY OF ESCAMBIA
Personally appeared before me ______________________ who states he/she read the foregoing
oath and is familiar with what it says and that he/she signed it freely and voluntarily, and in my
presence, and who is personally known to me ___________ or has produced
__________________________ as identification and who did/did not take an oath.
SWORN to before me this ________ day of _________, ______.
Signature of Notary Date
___________________________________
Commission Expiration Date
Rev. 04/2019
TRANSC
RIPT AGREEMENT FORM
I,_________________________, understand the position for which I am accepting/seeking
employment requires documentation from the college/university I attended. My signature below
acknowledges the following:
I understand that my continued employment as (check appropriate box)
a full-time faculty member
an adjunct instructor
is contingent upon the receipt of the official transcript(s) from the college(s) and universities I
attended.
It is my responsibility to follow-up on any official transcript request(s) submitted until all of my official
transcript(s) have been received by the Human Resources Department.
I understand I can be employed for only one academic term without having the official transcripts on
file. If my official transcripts are not on file by the end of my first academic term, I may not be eligible
to continue to teach at Pensacola State College.
I also understand that the renewal of my contract is contingent upon the review and approval of my
employment credentials by the appropriate Vice President, Dean, Department Head, and Director of
Human Resources.
Signature Date
HR Representative Date
NOTE: In order to comply with credentialing requirements, the Southern Association for Colleges
and Schools (SACS) requires Pensacola State College to provide evidence of official transcripts for
all instructional personnel at every college/university attended.
Rev. 04/2019
REQUEST FOR OFFICIAL TRANSCRIPT
____________________________________________________________________________________
Name of School, College or University
____________________________________________________________________________________
Address of School
____________________________________________________________________________________
City State Zip Code
Please Chec
k Request Type:
Mailed Online
Hardcopy transcript may be sent to: Electronic transcript may be sent to:
Pensacola State College
rlikely@pensacolastate.edu
Human Resources
Attn.: Rhonda A. Likely
1000 College Boulevard
Pensacola, FL 32504-8998
*If there is a fee for this service, please send the bill to the address shown below.
Student Information:
Name _______________________________________________________________________________________
Other Name(s) Used While Attending the Institution __________________________________________________
Birthdate ___________________________ Student Identification Number _______________________________
Date of Graduati
on __________________________ Date of Last Attendance _____________________________
Current Address ________________________________________________________________________________
______________________________________________________________________________________________
Signature
Date
__________________________________
NOTE: Some schools may require students to submit online transcript requests.
Rev. 04/2019
WORKERS’ COMPENSATION
Employees of Pensacola State College are covered for workers’ compensation. The Florida
College System Risk Management Consortium (FCSRMC) coordinates this program of self-
insurance, and Johns Eastern Company processes claims.
All accidents and incidents arising from an employee’s work must be reported to your supervisor.
After hours accidents may be reported to the Public Safety Department, at extension 2500. Please
see below and the following page for more information.
What if I require non-emergency care?
In case of an injury or illness on the job, after notifying your supervisor, contact the Pensacola
State College Human Resources Department, at extension 1766, immediately. The Human
Resources Director will refer you, as needed, for treatment and/or follow-up.
What if I require emergency care?
In the event of an emergency, proceed immediately to the nearest emergency facility. Care received
as follow up to an emergency treatment will be coordinated by the Human Resources Director at
extension 1766.
Rev. 05/2020
Dear Injured Employee:
Your employer’s insurance carrier is providing this information to you on behalf of the Employee
Assistance Office of the Division of Workers’ Compensation.
The Employee Assistance Office of the Division of Workers’ Compensation is a state bureau within
the Florida Department of Financial Services. We provide the following services:
Serves as a resource for injured workers and employers by providing information about the
workers’ compensation system.
Educates and informs injured workers, employers, carriers, health care providers, and
managed care arrangements about their responsibilities under the law.
Provides assistance in avoiding any problems or disputes regarding your claim.
Within three (3) days after receiving notice that you have been
injured, the workers’ compensation
insurance carrier will mail you an informational brochure explaining your rights and responsibilities as
well as the carrier’s obligations. It contains valuable information you need to know about the workers’
compensation system. You may have received the informational brochure along with this letter. You
can also obtain the brochure by calling
us at 1-800-342-1741 or e-mailing us at:
wceao@myfloridacfo.com.
You can also visit one of our local Employee Assistance Offices to receive personal, one-on-one
service. To locate the office nearest you, call the toll free 1-800 number above or visit the Division’s
website at: https://www.myfloridacfo.com/Division/WC/Employee/eao_offices.htm.
Sincerely,
Employee Assistance Office Division of Workers’ Compensation
Florida Department of Financial Services
FLORIDA DEPARTMENT OF FINANCIAL SERVICES
Division of Workers’ Compensation • Employee Assistance and Ombudsman Office
200 East Gaines Street • Tallahassee, Florida 32399-4225 • Tel. 1-800-342-1741
Email • wceao@MyFloridaCFO.com
AFFIRMATIVE ACTION • EQUAL OPPORTUNITY EMPLOYER
Rev. 04/2019
SOCIA
L SECURITY WITHHOLDINGS
BENCOR: FICA ALTERNATIVE PLAN 401(a)
PSC does not withhold Social Security taxes from an adjunct’s pay. However, participation is mandatory
in a Social Security alternative plan. The Omnibus Budget Reconciliation Act of 1990 introduced Federal
Legislation (Internal Revenue Code Section 312(B)(7)(F)) which allows the deposit of money into a
private retirement plan for part-time employees. PSC adopted this Social Security/FICA Alternative
Plan. The contribution of 7.5% of bi-weekly pay is deposited in an account in your name with BENCOR.
No taxes are paid on your contributions or earnings in your account until a withdrawal of funds is made,
and Social Security taxes are never paid on the funds. When an adjunct stops teaching, he or she is
eligible for a distribution of the account funds by contacting BENCOR at 888-258-3422 or going on-line
to https://bencorplans.usretirementpartners.com. Contact Human Resources at 850-484-1731 for
assistance.
Rev. 04/2019
Welcome to the BENCOR FICA Alternative Plan
Pensacola State College provides the BENCOR FICA Alternative Plan
as an important retirement benefit for all part-time, seasonal, and
temporary employees not covered under the Florida Retirement
System. The below guideline provides general information about the
plan and outlines available resources for obtaining further details:
Key Features of your FICA Alternative Plan
• All eligible employees are automatically enrolled in the program.
• All eligible employees make a 7.5% pre-tax contribution into a retirement account in their
name.
• All contributions permanently save Social Security taxes.
• Income taxes are deferred on contributions to the plan until you withdraw the money.
• Contributions are 100% vested.
Where Can You Get More Information?
1.
Your Employer’s Benefits Department
Access the FICA Welcome Letter for frequently asked questions
and plan videos through your employer’s benefits department or
benefits web portal.
2.
Online
www.bencorplans.com
Click on Participant Login, select your State, County, and Employer
then click on Log In. Enter your social security number as the User
ID and the last four digits of your social security number as the
Password. Select Participant from the drop down and Login, follow
the prompts to create your personalized security questions, user ID
and password.
3.
BENCOR National Participant Service Center
1-866-296-9712
(M-F 9:00 a.m. - 6:00 pm ET)
4.
Your local BENCOR Advisor:
Rodney Roberts (866) 447-1618
Rev. 04/2019
Once you ha
ve signed in, you can review the current status of your
account,
make changes, and access tools to help you personalize
your retirement
strategy. From the main menu, scroll over the five
tabs—Home, Review,
Manage, My Profile, and Resource Center—
and select the action you want
to take from the drop-down lists.
Check Account Balance
• Balance automatically appears on Account Overview page (in
the Home
menu at the top of the screen).
• For account balance by fund, click “Details.”
Review Investment Performance
• To get performance and fee details for all the funds in your
plan, in the
Review menu, click “Fund and Fee Information.”
Change Future Investment Allocations (new contributions)
• To choose or change how new contributions will be
invested, in the
Manage menu, click “Future Allocations.”
Transfer Between Investment Options (current assets)
• To transfer balances between individual or groups of
funds, in the
Manage menu, click “Transfers.”
• To change your overall investment mix, in the Manage
menu, click “Current Allocations.”
Forms and Beneficiary Information
• To locate forms and beneficiary information, in the Home
menu, select
“Forms” or “Beneficiaries.”
Customer Service
• From the top right on any page, select Help.
When you ent
er a change, a confirmation will be sent the following business
day. Changes that are completed prior to 4 p.m. ET will be valued using the
market closing unit values for that day. Changes completed after 4 p.m. ET will
be valued using the market closing unit values for the following business day.
Brighten Your Outlook
SM
Your plan website is the first step for anything you want to know about your
account.
Use it to sign in to your account, find information about your retirement
plan benefits, and learn more about saving for your future.
www.bencorplans.com
First-Time Users
•
Select “Participant Log On.”
•
Click “Get Started.”
•
Follow the instructions to establish
a customer ID and password.
Frequent Users
•
Click “Participant Log On.”
•
Sign in to your account by entering your
customer ID and pas
sword.
•
Click on the name of the account you
want to access.
Rev. 04/2019
Check Account Balance
• Account balance automatically offered.
• For account balance by fund, say “Account information,” then “Balances.”
Review Investment Performance
• Say “Hear account information.”
• Say “Fund information,” then “Performance.”
Change Future Investment Allocations (new contributions)
• Say “Change my account.”
• Say “Future allocation.”
• Provide updates to investment allocation. Confirmation sent the
following business day.
Please note that this allocation change impacts only
your
future contributions.
Transfer Between Investment Options (current assets)
• Say “Change my account.”
• Say “Transfer current assets.”
• Provide transfer information.
Confirmation sent the following business day.
Please note that changing current allocations does not
change
how your future contributions will be invested.
Customer Service
• Say “Speak to a counselor.”
TD-10969_BENCOR (10/13)
© 2013 Transamerica Retirement Solutions Corporation
Brighten Your Outlook
SM
Call 888-258-3422, option 1
First-Time Callers
• Call 888-258-3422, option 1.
• Enter your Social Security number.
• Follow the prompts for creating your
Personal Identification Number (PIN).
888-258-3422
Frequent Users
• Call 888-258-3422, option 1.
• Enter or say your Social Security number.
• Choose the account you wish to access.
• Enter or say your PIN.
Rev. 04/2019
PENSACOLA STATE COLLEGE - BENCOR 401(a) FICA ALTERNATIVE PLAN
Welcome to Pensacola State College BENCOR 401(a) FICA Alternative Plan (retirement plan). This letter provides general information about the
Plan and where to find more detailed information.
What is this retirement plan? The Pensacola State College BENCOR 401(a) FICA Alternative Plan (Plan) is a qualified retirement plan under Federal
tax law that covers part-time, seasonal and temporary employees of the College who are not covered by the Florida Retirement System. The Plan
provides an alternative benefit to Social Security and exempts you from FICA (Social Security) payroll taxes. You continue to pay Medicare taxes on
your wages. Enrollment in the Plan is automatic for every employee who works in a position covered by the Plan.
How much is contributed? You contribute 7.5% of your wages on a pre-tax basis (for income tax purposes) instead of paying Social Security taxes
that otherwise would be determined and paid by you on an after-tax basis. You will see your Plan contribution amount reflected on your paycheck
stub. Contributions are credited to an individual account in your name under the Plan.
How can I access my account? Go to www.bencorplans.com, click on Participant Log On, then select the Get Started box and follow the prompts
to create your personalized user ID and password.
FEATURES OF THE PARTICIPANT WEBSITE
* Unit Values
* Investment Fund Objectives
* Account Balance
* Fund Performance
* Account Balance, by Fund
* Address Changes
* Fund Transfers
* Investment Allocation Changes
* Online Beneficiary Designation
* Transaction History
* Download Forms
* Plan Overview
How is my account invested? The Plan offers different investment options in which you may choose to invest amounts contributed to your
account. If you do not choose investment options, your account will be invested automatically in the guaranteed option, which may or may not be
the best option for your particular circumstances. Therefore, it is very important for you to log on to your account at www.bencorplans.com as
soon as possible to obtain information about all the available investments and choose the options that are appropriate for your own objectives and
preferences.
Can I withdraw my account? Your account is always 100% vested and belongs only to you. The balance of your account will be available after your
termination of employment, retirement or total disability. In the case of your death, the beneficiary or beneficiaries you name under the Plan will
be able to withdraw your account balance. Funds may be withdrawn as a lump sum cash distribution, which is taxable for the year of withdrawal,
or as a direct rollover to an IRA or eligible retirement plan, which defers your income tax obligation. To request a withdrawal, download a
Distribution Request Form from www.bencorplans.com. Additional information about income taxes and rollovers is included with the form. Mail
your completed form to Pensacola State College, Human Resources, 1000 College Blvd., Pensacola, FL 32504.
Your account is subject to the IRS Required Minimum Distribution rules after you reach age 70 ½, or retirement, if later.
Individuals who are "active participants" for the year in certain tax-advantaged retirement plans, such as this FICA Alternative Plan, are subject to
federal tax law limitations on deducting contributions for the same year to an IRA account. These limitations also may affect a spouse's IRA
deductions. Consult an independent tax advisor if you wish to take federal income tax deductions for contributions to an IRA.
Will I receive statements? Annual statements showing your account activity and ending balance are provided after the close of each calendar year.
You may enroll in e-statements online to save mail time, paper and ink.
Are there any fees? There are no administrative fees charged to your account unless your balance is less than $1,000 and no contributions have
been made to your account for more than two years. At that time, if you do not elect a distribution, a monthly maintenance fee will apply.
How can I get more information? To logon to your account for plan and account information, go to www.bencorplans.com . Click on the
Participant Log On link to access your account. Logon tips for first time visitors are located on the logon page. After logging on, visit the
Communications section and choose Plan Related Forms for an overview of the plan and website, or dial a Bencor Customer Service
Representative at 1-888-258-3422, option 1. Representatives are available Monday – Friday, 8:30 a.m. through 5:00 p.m., Eastern Time.
BENCOR ADMINISTRATIVE SERVICES | 4333 EDGEWOOD ROAD NE | CEDAR RAPIDS, IA 52499
Rev. 04/2019
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Completed 25 August 2020

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