Fillable New Hire Packet (Edmonds Community College)

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New Hire Packet (Edmonds Community College)

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ACA_________ HR 11/2016 | HRPIF
Employee Personal Information Form
Employee type: ___Classified ___Student ___Volunteer ___PT Faculty ___FT Faculty ___Exempt _____PT Hourly
Department Name: ___________________________ Supervisor Name: __________________________________
YOUR PERSONAL INFORMATION
Last Name: ____________________________________ First Name:_____________________________________
Preferred Name: ______________________________________________________________________________
Street Address: _______________________________________________________________________________
City: __________________________________________ State: _______________ Zip code: _________________
Primary Phone number: ___________________________ Secondary Phone number: _______________________
Mailing Address (If different): ____________________________________________________________________
City: ________________________________________ State: _______________ Zip Code: ___________________
EMERGENCY CONTACT INFORMATION
Emergency Contact Name: _______________________________________________________________________
Relationship to self: ______________________________ Contact Phone: _________________________________
EMPLOYEE SIGNATURE REQUIRED
Employee Signature: __________________________________________ Date: ____________________________
FOR HUMAN RESOURCES OFFICE USE ONLY
Entered: _______________________________________ Date: ______________________________________
Form W-4 (2019)
Future developments. For the latest
information about any future developments
related to Form W-4, such as legislation
enacted after it was published, go to
www.irs.gov/FormW4.
Purpose. Complete Form W-4 so that your
employer can withhold the correct federal
income tax from your pay. Consider
completing a new Form W-4 each year and
when your personal or financial situation
changes.
Exemption from withholding. You may
claim exemption from withholding for 2019
if both of the following apply.
• For 2018 you had a right to a refund of all
federal income tax withheld because you
had no tax liability, and
• For 2019 you expect a refund of all
federal income tax withheld because you
expect to have no tax liability.
If you’re exempt, complete only lines 1, 2,
3, 4, and 7 and sign the form to validate it.
Your exemption for 2019 expires February
17, 2020. See Pub. 505, Tax Withholding
and Estimated Tax, to learn more about
whether you qualify for exemption from
withholding.
General Instructions
If you aren’t exempt, follow the rest of
these instructions to determine the number
of withholding allowances you should claim
for withholding for 2019 and any additional
amount of tax to have withheld. For regular
wages, withholding must be based on
allowances you claimed and may not be a
flat amount or percentage of wages.
You can also use the calculator at
www.irs.gov/W4App to determine your
tax withholding more accurately. Consider
using this calculator if you have a more
complicated tax situation, such as if you
have a working spouse, more than one job,
or a large amount of nonwage income not
subject to withholding outside of your job.
After your Form W-4 takes effect, you can
also use this calculator to see how the
amount of tax you’re having withheld
compares to your projected total tax for
2019. If you use the calculator, you don’t
need to complete any of the worksheets for
Form W-4.
Note that if you have too much tax
withheld, you will receive a refund when you
file your tax return. If you have too little tax
withheld, you will owe tax when you file your
tax return, and you might owe a penalty.
Filers with multiple jobs or working
spouses. If you have more than one job at
a time, or if you’re married filing jointly and
your spouse is also working, read all of the
instructions including the instructions for
the Two-Earners/Multiple Jobs Worksheet
before beginning.
Nonwage income. If you have a large
amount of nonwage income not subject to
withholding, such as interest or dividends,
consider making estimated tax payments
using Form 1040-ES, Estimated Tax for
Individuals. Otherwise, you might owe
additional tax. Or, you can use the
Deductions, Adjustments, and Additional
Income Worksheet on page 3 or the
calculator at www.irs.gov/W4App to make
sure you have enough tax withheld from
your paycheck. If you have pension or
annuity income, see Pub. 505 or use the
calculator at www.irs.gov/W4App to find
out if you should adjust your withholding
on Form W-4 or W-4P.
Nonresident alien. If you’re a nonresident
alien, see Notice 1392, Supplemental Form
W-4 Instructions for Nonresident Aliens,
before completing this form.
Specific Instructions
Personal Allowances Worksheet
Complete this worksheet on page 3 first to
determine the number of withholding
allowances to claim.
Line C. Head of household please note:
Generally, you may claim head of household
filing status on your tax return only if you’re
unmarried and pay more than 50% of the
costs of keeping up a home for yourself and
a qualifying individual. See Pub. 501 for
more information about filing status.
Line E. Child tax credit. When you file your
tax return, you may be eligible to claim a
child tax credit for each of your eligible
children. To qualify, the child must be under
age 17 as of December 31, must be your
dependent who lives with you for more than
half the year, and must have a valid social
security number. To learn more about this
credit, see Pub. 972, Child Tax Credit. To
reduce the tax withheld from your pay by
taking this credit into account, follow the
instructions on line E of the worksheet. On
the worksheet you will be asked about your
total income. For this purpose, total income
includes all of your wages and other
income, including income earned by a
spouse if you are filing a joint return.
Line F. Credit for other dependents.
When you file your tax return, you may be
eligible to claim a credit for other
dependents for whom a child tax credit
can’t be claimed, such as a qualifying child
who doesn’t meet the age or social
security number requirement for the child
tax credit, or a qualifying relative. To learn
more about this credit, see Pub. 972. To
reduce the tax withheld from your pay by
taking this credit into account, follow the
instructions on line F of the worksheet. On
the worksheet, you will be asked about
your total income. For this purpose, total
Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.
Form W-4
Department of the Treasury
Internal Revenue Service
Employee’s Withholding Allowance Certificate
a
Whether you’re entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
OMB No. 1545-0074
2019
1 Your first name and middle initial Last name
Home address (number and street or rural route)
City or town, state, and ZIP code
2 Your social security number
3
Single Married Married, but withhold at higher Single rate.
Note: If married filing separately, check “Married, but withhold at higher Single rate.”
4
If your last name differs from that shown on your social security card,
check here. You must call 800-772-1213 for a replacement card.
a
5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) .... 5
6 Additional amount, if any, you want withheld from each paycheck .............. 6
$
7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.
• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here . . .............
a
7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(This form is not valid unless you sign it.)
a
Date
a
8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete
boxes 8, 9, and 10 if sending to State Directory of New Hires.)
9 First date of
employment
10 Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 4.
Cat. No. 10220Q
Form W-4 (2019)
Form W-4 (2019)
Page 2
income includes all of your wages and
other income, including income earned by
a spouse if you are filing a joint return.
Line G. Other credits. You may be able to
reduce the tax withheld from your
paycheck if you expect to claim other tax
credits, such as tax credits for education
(see Pub. 970). If you do so, your paycheck
will be larger, but the amount of any refund
that you receive when you file your tax
return will be smaller. Follow the
instructions for Worksheet 1-6 in Pub. 505
if you want to reduce your withholding to
take these credits into account. Enter “-0-”
on lines E and F if you use Worksheet 1-6.
Deductions, Adjustments, and
Additional Income Worksheet
Complete this worksheet to determine if
you’re able to reduce the tax withheld from
your paycheck to account for your itemized
deductions and other adjustments to
income, such as IRA contributions. If you
do so, your refund at the end of the year
will be smaller, but your paycheck will be
larger. You’re not required to complete this
worksheet or reduce your withholding if
you don’t wish to do so.
You can also use this worksheet to figure
out how much to increase the tax withheld
from your paycheck if you have a large
amount of nonwage income not subject to
withholding, such as interest or dividends.
Another option is to take these items into
account and make your withholding more
accurate by using the calculator at
www.irs.gov/W4App. If you use the
calculator, you don’t need to complete any
of the worksheets for Form W-4.
Two-Earners/Multiple Jobs
Worksheet
Complete this worksheet if you have more
than one job at a time or are married filing
jointly and have a working spouse. If you
don’t complete this worksheet, you might
have too little tax withheld. If so, you will
owe tax when you file your tax return and
might be subject to a penalty.
Figure the total number of allowances
you’re entitled to claim and any additional
amount of tax to withhold on all jobs using
worksheets from only one Form W-4. Claim
all allowances on the W-4 that you or your
spouse file for the highest paying job in
your family and claim zero allowances on
Forms W-4 filed for all other jobs. For
example, if you earn $60,000 per year and
your spouse earns $20,000, you should
complete the worksheets to determine
what to enter on lines 5 and 6 of your Form
W-4, and your spouse should enter zero
(“-0-”) on lines 5 and 6 of his or her Form
W-4. See Pub. 505 for details.
Another option is to use the calculator at
www.irs.gov/W4App to make your
withholding more accurate.
Tip: If you have a working spouse and your
incomes are similar, you can check the
“Married, but withhold at higher Single
rate” box instead of using this worksheet. If
you choose this option, then each spouse
should fill out the Personal Allowances
Worksheet and check the “Married, but
withhold at higher Single rate” box on Form
W-4, but only one spouse should claim any
allowances for credits or fill out the
Deductions, Adjustments, and Additional
Income Worksheet.
Instructions for Employer
Employees, do not complete box 8, 9, or
10. Your employer will complete these
boxes if necessary.
New hire reporting. Employers are
required by law to report new employees to
a designated State Directory of New Hires.
Employers may use Form W-4, boxes 8, 9,
and 10 to comply with the new hire
reporting requirement for a newly hired
employee. A newly hired employee is an
employee who hasn’t previously been
employed by the employer, or who was
previously employed by the employer but
has been separated from such prior
employment for at least 60 consecutive
days. Employers should contact the
appropriate State Directory of New Hires to
find out how to submit a copy of the
completed Form W-4. For information and
links to each designated State Directory of
New Hires (including for U.S. territories), go
to www.acf.hhs.gov/css/employers.
If an employer is sending a copy of Form
W-4 to a designated State Directory of
New Hires to comply with the new hire
reporting requirement for a newly hired
employee, complete boxes 8, 9, and 10 as
follows.
Box 8. Enter the employer’s name and
address. If the employer is sending a copy
of this form to a State Directory of New
Hires, enter the address where child
support agencies should send income
withholding orders.
Box 9. If the employer is sending a copy of
this form to a State Directory of New Hires,
enter the employee’s first date of
employment, which is the date services for
payment were first performed by the
employee. If the employer rehired the
employee after the employee had been
separated from the employer’s service for
at least 60 days, enter the rehire date.
Box 10. Enter the employer’s employer
identification number (EIN).
Form W-4 (2019)
Page 3
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself .............................. A
B Enter “1” if you will file as married filing jointly ....................... B
C Enter “1” if you will file as head of household . . . .................... C
D Enter “1” if:
{
• You’re single, or married filing separately, and have only one job; or
• You’re married filing jointly, have only one job, and your spouse doesn’t work; or
• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
}
D
E Child tax credit. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each
eligible child.
• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for
each eligible child.
• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” .......
E
F Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.
• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.
• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every
two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have
four dependents).
• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” .......
F
G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet
here. If you use Worksheet 1-6, enter “-0-” on lines E and F ..................
G
H Add lines A through G and enter the total here . . ....................
a
H
For accuracy,
complete all
worksheets
that apply.
{
• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you
have a large amount of nonwage income not subject to withholding and want to increase your withholding,
see the Deductions, Adjustments, and Additional Income Worksheet below.
• If you have more than one job at a time or are married filing jointly and you and your spouse both
work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the
Two-Earners/Multiple Jobs Worksheet on page 4 to avoid having too little tax withheld.
• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form
W-4 above.
Deductions, Adjustments, and Additional Income Worksheet
Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage
income not subject to withholding.
1
Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of
your income. See Pub. 505 for details ...................... 1
$
2 Enter:
{
$24,400 if you’re married filing jointly or qualifying widow(er)
$18,350 if you’re head of household
$12,200 if you’re single or married filing separately
}
........... 2
$
3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . .............. 3
$
4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any
additional standard deduction for age or blindness (see Pub. 505 for information about these items) . .
4
$
5 Add lines 3 and 4 and enter the total ...................... 5
$
6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) . 6
$
7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7
$
8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.
Drop any fraction ............................
8
9 Enter the number from the Personal Allowances Worksheet, line H, above . . ........ 9
10
Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/
Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here
and enter this total on Form W-4, line 5, page 1 ...................
10
Form W-4 (2019)
Page 4
Two-Earners/Multiple Jobs Worksheet
Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.
1
Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the
Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that
worksheet) .............................. 1
2
Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re
married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for
you and your spouse are $107,000 or less, don’t enter more than “3” . . . . . . . . .....
2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”)
and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . ..........
3
Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet ........... 4
5 Enter the number from line 1 of this worksheet ........... 5
6 Subtract line 5 from line 4 .......................... 6
7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here ..... 7
$
8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8
$
9
Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every
2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in
2019. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld
from each paycheck ...........................
9
$
Table 1
Married Filing Jointly
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $5,000 0
5,001 - 9,500 1
9,501 - 19,500 2
19,501 - 35,000 3
35,001 - 40,000 4
40,001 - 46,000 5
46,001 - 55,000 6
55,001 - 60,000 7
60,001 - 70,000 8
70,001 - 75,000 9
75,001 - 85,000 10
85,001 - 95,000 11
95,001 - 125,000 12
125,001 - 155,000 13
155,001 - 165,000 14
165,001 - 175,000 15
175,001 - 180,000 16
180,001 - 195,000 17
195,001 - 205,000 18
205,001
and over
19
All Others
If wages from LOWEST
paying job are—
Enter on
line 2 above
$0 - $7,000 0
7,001 - 13,000 1
13,001 - 27,500 2
27,501 - 32,000 3
32,001 - 40,000 4
40,001 - 60,000 5
60,001 - 75,000 6
75,001 - 85,000 7
85,001 - 95,000 8
95,001 - 100,000 9
100,001 - 110,000 10
110,001 - 115,000 11
115,001 - 125,000 12
125,001 - 135,000 13
135,001 - 145,000 14
145,001 - 160,000 15
160,001 - 180,000 16
180,001 and over 17
Table 2
Married Filing Jointly
If wages from HIGHEST
paying job are—
Enter on
line 7 above
$0 - $24,900 $420
24,901 - 84,450 500
84,451 - 173,900 910
173,901 - 326,950 1,000
326,951 - 413,700 1,330
413,701 - 617,850 1,450
617,851
and over
1,540
All Others
If wages from HIGHEST
paying job are—
Enter on
line 7 above
$0 - $7,200 $420
7,201 - 36,975 500
36,976 - 81,700 910
81,701 - 158,225 1,000
158,226 - 201,600 1,330
201,601 - 507,800 1,450
507,801 and over 1,540
Privacy Act and Paperwork Reduction
Act Notice. We ask for the information on
this form to carry out the Internal Revenue
laws of the United States. Internal Revenue
Code sections 3402(f)(2) and 6109 and
their regulations require you to provide this
information; your employer uses it to
determine your federal income tax
withholding. Failure to provide a properly
completed form will result in your being
treated as a single person who claims no
withholding allowances; providing
fraudulent information may subject you to
penalties. Routine uses of this information
include giving it to the Department of
Justice for civil and criminal litigation; to
cities, states, the District of Columbia, and
U.S. commonwealths and possessions for
use in administering their tax laws; and to
the Department of Health and Human
Services for use in the National Directory of
New Hires. We may also disclose this
information to other countries under a tax
treaty, to federal and state agencies to
enforce federal nontax criminal laws, or to
federal law enforcement and intelligence
agencies to combat terrorism.
You aren’t required to provide the
information requested on a form that’s
subject to the Paperwork Reduction Act
unless the form displays a valid OMB
control number. Books or records relating
to a form or its instructions must be
retained as long as their contents may
become material in the administration of
any Internal Revenue law. Generally, tax
returns and return information are
confidential, as required by Code section
6103.
The average time and expenses required
to complete and file this form will vary
depending on individual circumstances.
For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this
form simpler, we would be happy to hear
from you. See the instructions for your
income tax return.
USCIS
Form I-9
OMB No. 1615-
0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Page 1 of 4
Form I-9 07/17/17 N
►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)
Number City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security
Number
Employee's E-mail Address
Employee's Telephone Number
-
-
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):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)
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:
OR
2.
Form I-94 Admission Number:
OR
3.
Foreign Passport Number:
Country of Issuance:
QR Code - Section 1
Do Not Write In This Space
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
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.)
Signature of Employee
Today's Date (mm/dd/yyyy)
USCIS
Form I-9
OMB No. 1615-
0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Page 2 of 4
Form I-9 07/17/17 N
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 docume
nt 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.")
Employee Info from Section
Last Name (Family Name)
First Name (Given Name)
M.I. Citizenship/Immigration Status
List A OR List B AND List C
Identity and Employment Authorization Identity
Employment Authorization
Document Title
Document Title
Document Title
Issuing Authority
Issuing Authority
Issuing Authority
Document Number
Document Number
Document Number
Expiration Date (if
Expiration Date (if
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Issuing Authority
Document Number
Expiration Date (if
Document Title
Issuing
Document
Expiration Date (if
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)
Signature of Employer or Authorized Representative
Today's Date
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
City or Town
State
ZIP Code
USCIS
Form I-9
OMB No. 1615-
0047
Expires 08/31/2019
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Page 3 of 4
Form I-9 07/17/17 N
Employee Name from Section 1:
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Section 3. Reverification and Rehires
(To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
B. Date of Rehire (if applicable)
Last Name (Family Name)
First Name
(Given Name)
Middle Initial
Date
(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.
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
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
Form I-9 07/17/17 N
Page 4 of 4
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
Documents that Establish
Both Identity and
Employment Authorization
OR
LIST B LIST C
Documents that Establish
Documents that Establish
Identity
Employment Authorization
AND
1. U.S. Passport or U.S. Passport Card 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
1.
A Social Security Account Number
card, unless the card includes one of
the following restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2)
VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3)
VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
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. Employment Authorization Document
that contains a photograph (Form
I-766)
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. School ID card with a photograph
5.
For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
a.
Foreign passport; and
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.
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. Voter's registration card
5. U.S. Military card or draft record
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
4. Native American tribal document
5. U.S. Citizen ID Card (Form I-197)
8. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
9. Driver's license issued by a Canadian
government authority
For persons under age 18 who are
unable to present a document
listed above:
7. Employment authorization
document issued by the
Department of Homeland Security
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
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
HR 11/2016 | HRDEMO
Employee Demographic Data Form
Government agencies require periodic reports on the gender, ethnic origin, and veteran status of employees. Persons hired
or already employed by the college are required to provide the information below. This information will be treated as
confidential and will be available only to authorized personnel.
Last Name: ______________________________________
First Name: ______________________________________
Social Security Number: ____________________________
Birthdate: ____________________ __ FEMALE __ MALE
ETHNICITY/HISPANIC ORIGIN
ARE YOU OF HISPANIC ORIGIN? ___yes (717) ___no (999)
Hispanic origin includes all persons having origins in Mexico, Puerto Rico, Cuba, Central or South America, or other countries of Spanish culture, regardless
of race. It does not include persons from Portuguese speaking cultures such as Portugal or Brazil. The Spanish/Hispanic/Latino question is about ethnicity,
not race.
RACE INFORMATION (CHECK ALL THAT APPLY)
__ AMERICAN INDIAN (597) or __ ALASKAN NATIVE (015)
A person having origins in any of the original peoples of North and South America
(including Central America), and who maintains a tribal affiliation or community
attachment.
__ ASIAN (621)
A person having origins in any of the original peoples of the Far
East, Southeast Asia, or the Indian Subcontinent including, but not
limited to, Cambodia, China, India, Japan, Korea, Malaysia,
Pakistan, the Philippine Islands, Thailand, and Vietnam.
__ NATIVE HAWAIIAN (653) or __ Other PACIFIC ISLANDER (681)
A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or
other Pacific Islands.
__ WHITE/CAUCASIAN (800)
A person with origins in any of the original peoples of Europe,
North Africa, or the Middle East.
__ BLACK/AFRICAN-AMERICAN (870)
A personal having origins in any of the Black racial groups of Africa.
VETERAN STATUS (CHECK ALL THAT APPLY)
__ NOT A VETERAN
__ VIETNAM-ERA VETERAN (VV)
__ NON VIETNAM-ERA VETERAN (OV)
__ SPOUSE OF DECEASED VETERAN (SV)
__ DISABLED VETERAN (% OF DISABILITY ____) (DV) (DO)
DATES OF SERVICE: _________________________________
Vietnam-era Veteran: A person who served on active duty for more than 180 days, any part of which occurred between August 5, 1964 and May 7,
1975, and was discharged or released from duty with other than a dishonorable discharge.
Disabled Veteran: A person entitled to disability compensation under laws administered by the U.S. Department of Veterans Affairs for disability rated
at 30 percent or more, or rated at 10 or 20 percent in the case of a veteran who has been determined to have a serious employment handicap, or a person
whose discharge or release from active duty was for a disability incurred or aggravated in the line of duty.
DISABILITY INFORMATION
__ YES __ NO Do you have a physical, sensory, or mental condition that substantially limits any of your major life
functions, such as working, caring for yourself, walking, doing things with your hands, seeing, hearing, speaking, or
learning?
Disability definition: For Affirmative Action purposes, people with disabilities are persons with a permanent physical, mental, or sensory impairment
which substantially limits one or more major life activities. Physical, mental or sensory impairment means: (a) any physiological or neurological disorder or
condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems or functions; or (b) any mental or psychological disorders
such as mental retardation, organic brain syndrome, emotional or mental illness, or any specific learning disability. The impairment must be material
rather than slight, and permanent in that it is seldom fully corrected by medical replacement, therapy, or surgical means
.
I certify that this information is true and accurate to the best of my knowledge.
EMPLOYEE SIGNATURE: ________________________________________ DATE: __________________________________
RETURN COMPLETED FORM TO HUMAN RESOURCES
Employer Signature
I have veried the information above using MRV or by contacting a DRS representative. I acknowledge that failure to properly report
a retiree to DRS can result in a liability to the employer.
Employer Signature Date
Employer Comments (optional)
Please enter any additional comments here. If you need more room, use the back of this form and check this box: c
Employee Information
Employer
Verication
Employee Name (Last, First, Middle) Social Security Number
Are you a retiree of one of Washington state’s retirement systems? If yes, which one(s)?
c Yes, _______________________________________________________________________________________ c No
c Yes c No
Are you a retiree of a separate retirement plan covered by the city of Seattle, Spokane or Tacoma?
If yes, which one(s)?
c Yes, _______________________________________________________________________________________ c No
If the employee checked yes,
stop. Contact ESS before
enrolling the employee in a
DRS retirement plan.
Are you currently employed by another public employer and contributing to a Washington state
retirement system? That is, will you be working at the same time for two public employers?
c Yes c No
If the employee checked yes,
stop. Contact ESS before
enrolling the employee in a
DRS retirement plan.
Employee Signature Date
Retirement Status
Verication
Employers can use this form to document
the retirement status of all new employees,
as required by RCW 41.50.139.
Contact Information for
Employer Support Services at DRS
360.664.7200, option 2
800.547.6657, option 6, option 2
employersupport@drs.wa.gov
Employer Instructions
RCW 41.50.139 requires employers to obtain, in writing, the retirement status of all new employees. Employers
can document retirement status through their own processes or by using this DRS form. If using this form,
follow these instructions:
• Ask the employee to complete and sign the Employee Information section below.
• Use Member Reporting Verication (MRV) to review the employee’s retirement status.
• Record the results in the Employer Verication section below.
• Determine whether the employee retired using the 2008 Early Retirement Factors. c Yes c No
If yes, contact DRS Employer Support Services (ESS) immediately.
• Use Retiree Return to Work (RRTW) Reporting Charts to review reporting instructions as necessary.
• Sign and date this form.
• Retain this form for 60 years.
*DRSMS147*
DRS MS 147 (5/16)
Clear Form
Revised: 11/2016 1
ACA Code
Y3 = 130 or more hrs/mo
ACA Employee Status
Enter the ACA code that best describes the employee.
Employee: A new or returning employee who does not meet the definition
of "educational organization" or "seasonal" employee.
(Employer must assume the employee will be employed for the next 12 months, even if
hired to work less than 12 months).
Affordable Care Act
Employee Email Address: (optional)
Employee Name:
Employee ID:
Worksheet Reminders:
N2 = Less than 130 hrs/mo
Educational Organization Employee: A new or returning employee
employed by an educational organization (e.g., primary, secondary,
preparatory and high schools, colleges and universities).
(Employer must assume the employee will be employed for the next 12 months, even if
hired to work less than 12 months).
N1 = Less than 130 hrs/mo
Worksheet A-0:
ACA employee status
• This worksheet helps determine if an employee meets the federal definition of full-time for reporting
purposes.
• An "employee" in any of the definitions of employee types below, is anyone paid for service. In
addition to the PEBB definition of an employee, this includes others paid for service, such as students or
board members.
Federal Reporting Requirements (Affordable Care Act)
Y1 = 130 or more hrs/mo
Type of Employee ACA Codes
Y2 = 130 or more hrs/mo
The Affordable Care Act (ACA) requires employers to determine the anticipated average hours of service of new
and returning employees and employees who experience a change in employment status. The employer may be
required to enter the ACA code into the system of record or PAY1, based on the method chosen by your agency.
When determining the ACA code, consider the employee's anticipated average hours of service over the next 12
months. See the ACA Employee Status Code Instructions on the PersPay website for more information.
The ACA definition of full-time does not determine eligibility for PEBB benefits.
N3 = Less than 130 hrs/mo
Seasonal: A new or returning employee anticipated to work on a seasonal
basis (specific time of the year) for 6 months or less, who does not meet the
definition of "educational organization employee."
(Consider the next 12-month period, including months with zero hours of pay status, when
calculating average hours/month. If the season is more than 6 months, calculate the ACA
code according to "employee" type above).
HR 6/2017 |HREFT
ABOUT YOUR PAYROLL FUNDS
Bellevue Community College Payroll Office: 425-640-1492
Edmonds Community College Human Resources Office: 425-640-1400
1. Employees have 2 options for receiving their payroll funds:
Direct Deposit (electronic funds transfer, EFT)
OR
Focus Card (Visa prepaid card)
2. You will receive a paper check the first payroll after submission of the Payment Authorization Form.
This check will be mailed to your home address via the U.S. Postal Service.
3. Some banks may post your automatic payroll deposit later than the hour the bank opens. Consult with your
bank for the time of day your funds will be available to you.
4. It is the employee’s responsibility to notify the payroll office of any bank or account information changes that
occur. Failure to do so may result in a delayed payment to the employee of up to 5 days after the pay date.
5. The Employee Earnings & Leave Web application will also show whether a Focus debit card or a direct deposit
was created for each payroll run. You can access your payroll information via the Employee Earning & Leave Web
application: https://transact.edcc.edu/empearnlv/
The Affordable Care Act (ACA) Notice of Health Insurance Marketplace/Coverage Options and Your Public Employees Benefits
Board (PEBB) Benefits
General Information
Beginning in 2014, most individuals will be required to have health insurance coverage. There will be a new way to buy health
insurance through the new health insurance Marketplace, also known as the Health Benefit Exchange. Washington Healthplanfinder
is the Marketplace serving Washington residents. This notice provides basic information about the Marketplace as well as PEBB
benefits offered by your employer and is intended to assist you in evaluating options for you and your family.
1. What is the Health Insurance Marketplace?
Under the ACA, every state must have a health insurance Marketplace to help people buy health insurance. The Marketplace
offers assistance to help you find and compare medical health insurance options offered by private companies. The Marketplace
will also help you find out if you qualify for premium tax credits or other financial assistance.
2. When does open enrollment begin?
Open enrollment for the Marketplace begins November 1, 2016 for coverage starting January 1, 2017.
3. Can I save money on my health insurance premiums in the Marketplace?
You may qualify to save money and lower your monthly premium, but only if you are not
eligible for PEBB medical plan
enrollment as an employee. The amount of premium savings in the Marketplace depends on your household income.
4. Does being eligible for an employer contribution for PEBB medical coverage affect eligibility for premium savings through the
Healthplanfinder? Yes.
● Employees eligible for employer contribution:
All eligible state employees receive an employer contribution for PEBB medical plan enrollment and are not allowed to
waive PEBB medical coverage to enroll in coverage through the Marketplace. All or a portion of this contribution may be
excluded from income for Federal and State income tax purposes. These employees should remain enrolled in their PEBB
medical plan.
State employees who are eligible to receive an employer contribution cannot use the employer contribution to purchase
coverage through the Marketplace, and will not be eligible for a premium tax credit if they purchase coverage through the
Marketplace.
However, if the cost of a PEBB health plan to cover you (and not any other members of your family) is more than 9.5% of
your household income for the year, or does not meet the “minimum value” standard set by the ACA, you may be eligible
for a tax credit or other financial assistance.
An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit
costs covered by the plan is no less than 60 percent of such costs.
● Employees not
eligible for employer contribution:
Employees who are not eligible for the employer contribution for PEBB medical plan enrollment should consider applying
for health benefits in the new Marketplace as they may qualify for a premium tax credit or other financial assistance. Your
payments for coverage through the Marketplace are made on an after-tax basis.
5. How do I get additional information about the Marketplace?
The Marketplace simplifies your search for health coverage by gathering the options available in your area in one place. You can
compare plans based on price, benefits, quality, and other features important to you before you make a choice.
Visit www.healthcare.gov
(with a live chat option) or also get help by phone, or in person.
Call 1-800-318-2596, 24 hours a day, 7 days a week. (TTY: 1-855-889-4325).
6. How do I contact the Washington Healthplanfinder?
For help with your Washington Healthplanfinder application or to get answers about coverage, call our Customer Support
Center. Help is available in 175 languages. Language and disability accommodations are provided at no cost.
Toll-free: 1-855-923-4633
TTY: 1-855-627-9604
Hours: 8 a.m. to 8 p.m. Monday – Friday
Email: customersupport@wahbexchange.org
7. How do I get more information about PEBB benefits?
For more information about PEBB health plans offered by your employer, please check the Certificate of Coverage for your plan,
or contact your benefits office.
You can also find complete information about PEBB benefits at the PEBB website:
www.hca.wa.gov/pebb
Information about PEBB health coverage offered by your employer
This section contains information about any health coverage offered by your employer. If you decide to complete an application for
coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the
Marketplace application.
3. Employer name
Edmonds Community College
4. Employer Identification Number (EIN)
910825212
5. Employer address
20000 68
th
Ave West
6. Employer phone number
(425)640-1077
7. City
Lynnwood
8. State
WA
9. ZIP code
98036-5999
10. Who can we contact about employee health coverage at this job?
Debbie Lau (employees with last names N-Z, all PTF)
Denise Olson (employees with last names A-M, all Hourly)
11. Phone number (if different from above)
(425) 640-1077
(425) 640-1069
12. Email address
dlau@edcc.edu
Denise.Olson@edcc.edu
Information about health coverage offered by this employer:
• As your employer, we offer a health plan to:
All employees.
Some employees.
Eligible employees are described in Washington Administrative Code 182-12-114:
(1)(a) An employee is eligible if he or she works an average of at least eighty hours per month and works for at least eight hours
in each month for more than six consecutive months.
(i)Upon employment: An employee is eligible from the date of employment if the employing agency anticipates the employee
will work according to the criteria in (a) of this subsection.
(2)(a) Seasonal employees are eligible if he or she works an average of at least eighty hours per month and works for at least
eight hours in each month of the season. A season is any recurring, cyclical period of work at a specific time of year that lasts
three to eleven months.
(b) Determining eligibility.
(i) Upon employment: A seasonal employee is eligible from the date of employment if the employing agency anticipates that he
or she will work according to the criteria in (a) of this subsection.
(ii) Upon revision of anticipated work pattern. If an employing agency revises an employee's anticipated work hours such that
the employee meets the eligibility criteria in (a) of this subsection, the employee becomes eligible when the revision is made.
(iii) Based on work pattern. An employee who is determined to be ineligible for benefits, but later works an average of at least
eighty hours per month and works for at least eight hours in each month and works for more than six consecutive months,
becomes eligible the first of the month following a six-month averaging period.
(c) Stacking of hours. As long as the work is within one state agency, employees may "stack" or combine hours worked in more
than one position or job to establish eligibility and maintain the employer contribution toward insurance coverage. Employees
must notify their employing agency if they believe they are eligible through stacking. Stacking includes work situations in which:
(i) The employee works two or more positions or jobs at the same time (concurrent stacking);
(ii) The employee moves from one position or job to another (consecutive stacking); or
(iii) The employee combines hours from a seasonal position or job to hours from a nonseasonal position or job. An employee
who establishes eligibility by stacking hours from a seasonal position or job with hours from a nonseasonal position or job shall
maintain the employer contribution toward insurance coverage under WAC 182-12-131(1).
(3)(a) Faculty "Half-time" means one-half of the full-time academic workload as determined by each institution, except that
half-time for community and technical college faculty employees is governed by RCW 28B.50.489.
Note: A change to the definition of full time, for community and technical college faculty, based on a collective bargaining
agreement may affect an employee’s eligibility for PEBB benefits. If eligibility is lost, COBRA coverage is available as described in
WAC 182-12-146.
(i) Upon employment: Faculty who the employing agency anticipates will work half-time or more for the entire instructional
year, or equivalent nine-month period, are eligible from the date of employment.
(ii) For faculty hired on quarter/semester to quarter/semester basis: Faculty who the employing agency anticipates will not
work for the entire instructional year, or equivalent nine-month period, are eligible at the beginning of the second consecutive
quarter or semester of employment in which he or she is anticipated to work, or has actually worked, half-time or more. Spring
and fall are considered consecutive quarters/semesters when first establishing eligibility for faculty that work less than half-time
during the summer quarter/semester.
(iii) Upon revision of anticipated work pattern: Faculty who receive additional workload after the beginning of the anticipated
work period (quarter, semester, or instructional year), such that their workload meets the eligibility criteria of (a)(i) or (ii) of this
subsection become eligible when the revision is made.
(b) Stacking. Faculty may establish eligibility and maintain the employer contribution toward insurance coverage by working as
faculty for more than one institution of higher education. Faculty workloads may only be stacked with other faculty workloads
to establish eligibility under this section or maintain eligibility under WAC 182-12-131(3). When a faculty works for more than
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one institution of higher education, the faculty must notify his or her employing agencies that he or she works at more than one
institution and may be eligible through stacking
(4)(a) Elected and full-time appointed officials of the legislative and executive branches of state government are eligible for
PEBB benefits on the date his or her term begins. All other elected and full-time appointed officials of the legislative and
executive branches of state government are eligible on the date their terms begin or the date they take the oath of office,
whichever occurs first.
(5)(a) Justices and judges are eligible for PEBB benefits on the date they take the oath of office.
• With respect to dependents:
We do offer coverage.
We do not offer coverage.
Eligible dependents are described in Washington Administrative Code 182-12-260:
(1) Lawful spouse.
(2) Domestic partner. (a) Effective January 1, 2010, a state registered domestic partner, as defined in RCW 26.60.020(1). (b) A
domestic partner who was qualified under PEBB eligibility criteria as a domestic partner before January 1, 2010, and was
continuously enrolled under the subscriber in a PEBB health plan or life insurance.
(3) Children. Children are eligible up to age twenty-six except as described in subsection (i) of this section. Children are defined
as the subscriber's:
(a) Children as defined in RCW 26.26.101 establishment of parent-child relationship;
(b) Biological children;
(c) Stepchildren. The stepchild’s relationship to a subscriber (and eligibility as a PEBB dependent) ends, for purposes of this
rule, on the same date the subscriber’s legal relationship with the spouse or domestic partner ends through divorce, annulment,
dissolution, termination, or death;
(d) Legally adopted children;
(e) Children for whom the subscriber has assumed a legal obligation for total or partial support in anticipation of adoption of
the child;
(f) Children of the subscriber's state registered domestic partner;
(g) Children specified in a court order or divorce decree;
(h) Extended dependents in the legal custody or legal guardianship of the subscriber, the subscriber's spouse, or subscriber's
state registered domestic partner. The legal responsibility is demonstrated by a valid court order and the child's official
residence with the custodian or guardian. "Children" does not include foster children for whom support payments are made to
the subscriber through the state department of social and health services foster care program; and
(i) Children of any age with a disability. Effective January 1, 2011, children of any age with a disability, mental illness, or
intellectual or other developmental disability, who are incapable of self-support, provided such condition occurs before age
twenty-six. Periodic certification is required.
(4) Parents.
(a) Parents covered under PEBB medical before July 1, 1990, may continue enrollment on a self-pay basis as long as:
(i) The parent maintains continuous enrollment in PEBB medical;
(ii) The parent qualifies under the Internal Revenue Code as a dependent of the subscriber;
(iii) The subscriber continues enrollment in PEBB insurance coverage; and
(iv) The parent is not covered by any other group medical plan.
(b) Parents eligible under this subsection may be enrolled with a different health plan than that selected by the subscriber.
Parents may not add additional dependents to their insurance coverage.
If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be
affordable, based on employee wages.
Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount through the
Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be
eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or
you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify
for a premium discount.
11/2016
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