PRE-EMPLOYMENT CHECKLIST
Employee Information Form _____
Complete, sign and date the bottom of the form.
Form I9 and Instructions _____
Newly hired employees must complete Section I of this form no later than their first date of
employment. Employees must provide documents within three (3) days of their date of hire.
Complete, sign and date the bottom of the form.
Note: For further instructions on how to complete the Form I9, please refer to the Human
Resources website or click on the following link: https://brockton.ma.us/city-
departments/human-resources/
W4 Federal Tax Form _____
Complete, sign and date the bottom of the form.
M4 State Tax Form _____
Complete, sign and date the bottom of the form.
Direct Deposit Form _____
Payroll checks will be directly deposited into your checking or savings account. You are allowed
up to five (5) account deposits.
Form SSA-1945 _____
Sign and date bottom of the form. This form explains information about the possible effects of
the Windfall Elimination Provision and the Government Pension Offset Provision on your
potential future Social Security benefits.
Voluntary Self ID Form _____
Completion of this form is strictly voluntary, but will enable the City of Brockton to accurately
report the diversity of its employees.
CITY OF BROCKTON
DEPARTMENT OF HUMAN RESOURCES
45 SCHOOL STREET
BROCKTON, MA
(508) 580-7820
All new employees must acknowledge and complete the attached Pre-employment
Paperwork. If completed on-line, print, sign and return to Human Resources,
Brockton City Hall, 2
nd
floor.
Note: Benefitted appointees must also complete mandatory benefits paperwork.
Voluntary Self ID of Disability _____
Completion of this form is strictly voluntary, but will enable the City of Brockton to accurately
report the diversity of its employees.
MA Family Disclosure Form _____
If applicable, complete the form by including the name(s) of family members who are employees
by the state.
Conflict of Interest Requirements _____
Annual conflict of interest law education and training is required by the City of Brockton and the
Commonwealth of Massachusetts.
Notice of Residency _____
City of Brockton mandates that an employee must be a resident of the City of Brockton or shall,
within one (1) year of employment establish residency within the City.
CORI Acknowledgement & Authorization Form _____
Complete, sign and date the form authorizing the City of Brockton to perform a background
check.
Name (Signature):______________________________Department:_____________________
Name (Print):__________________________________Date:___________________________
I have received, completed, and understand the forms and information listed above. I also understand
that my name will not be added to the City of Brockton’s payroll until all of the appropriate
paperwork is properly completed and submitted to the Department of Human Resources.
First Name
Middle Name
Last Name
Birth Date
Place of Birth
EMERGENCYCONTACTS
Name
Address
Telephone
Relationship
PRIMARY
SECONDARY
Other
Educational Level
Degree
Major
School Name
Year Awarded
High School/Equivalent
College/University
Master’s Level
Technical
Other
PRIOR
SERVICE IN ANY MASSACHUSETTS GOVERNMENT AGENCY
If retired from any government agency: (CHECK)
Name of Agency
From
To
Sig
nature: Date:
CITY OF BROCKTON
Department of Human Resources
EMPLOYEE INFORMATION FORM
Social Security Number_________________________________________
Telephone
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Form
W-4
Department of the Treasury
Internal Revenue Service
Employee’s Withholding Certificate
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
2020
Step 1:
Enter
Personal
Information
(a) First name and middle initial
Last name
(b) Social security number
Address
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
City or town, state, and ZIP code
(c) Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 24 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the online estimator, and privacy.
Step 2:
Multiple Jobs
or Spouse
Works
Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse
also works. The correct amount of withholding depends on income earned from all of these jobs.
Do only one of the following.
(a)
Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 34); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment
income, including as an independent contractor, use the estimator.
Complete Steps 34(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 34(b) on the Form W-4 for the highest paying job.)
Step 3: If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Claim
Dependents
Multiply the number of qualifying children under age 17 by $2,000
$
Multiply the number of other dependents by $500 . . . .
$
Add the amounts above and enter the total here . . . . . . . . . . . . .
3
$
Step 4
(a) Other income (not from jobs). If you want tax withheld for other income you expect
(optional):
this year that won’t have withholding, enter the amount of other income here. This may
Other
include interest, dividends, and retirement income . . . . . . . . . . . .
Adjustments
(b)
Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here . . . . . . . . . . . . . . . . . . . . .
(c)
Extra withholding. Enter any additional tax you want withheld each pay period .
4(a)
$
4(b)
$
4(c)
$
Step 5:
Sign
Here
Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
Employee’s signature (This form is not valid unless you sign it.) Date
Employers
Only
Employer’s name and address
First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2020)
Page 2
Form W-4 (2020)
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you will
generally be due a refund. Complete a new Form W-4 when
changes to your personal or financial situation would change
the entries on the form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
Exemption from withholding. You may claim exemption from
withholding for 2020 if you meet both of the following
conditions: you had no federal income tax liability in 2019 and
you expect to have no federal income tax liability in 2020. You
had no federal income tax liability in 2019 if (1) your total tax on
line 16 on your 2019 Form 1040 or 1040-SR is zero (or less
than the sum of lines 18a, 18b, and 18c), or (2) you were not
required to file a return because your income was below the
filing threshold for your correct filing status. If you claim
exemption, you will have no income tax withheld from your
paycheck and may owe taxes and penalties when you file your
2020 tax return. To claim exemption from withholding, certify
that you meet both of the conditions above by writing “Exempt”
on Form W-4 in the space below Step 4(c). Then, complete
Steps 1a, 1b, and 5. Do not complete any other steps. You will
need to submit a new Form W-4 by February 16, 2021.
Your privacy. If you prefer to limit information provided in
Steps 2 through 4, use the online estimator, which will also
increase accuracy.
As an alternative to the estimator: if you have concerns
with Step 2(c), you may choose Step 2(b); if you have
concerns with Step 4(a), you may enter an additional amount
you want withheld per pay period in Step 4(c). If this is the
only job in your household, you may instead check the box
in Step 2(c), which will increase your withholding and
significantly reduce your paycheck (often by thousands of
dollars over the year).
When to use the estimator. Consider using the estimator at
www.irs.gov/W4App if you:
1.
Expect to work only part of the year;
2.
Have dividend or capital gain income, or are subject to
additional taxes, such as the additional Medicare tax;
3.
Have self-employment income (see below); or
4.
Prefer the most accurate withholding for multiple job
situations.
Self-employment. Generally, you will owe both income and
self-employment taxes on any self-employment income you
receive separate from the wages you receive as an
employee. If you want to pay these taxes through
withholding from your wages, use the estimator at
www.irs.gov/W4App to figure the amount to have withheld.
Nonresident alien. If you’re a nonresident alien, see Notice
1392, Supplemental Form W-4 Instructions for Nonresident
Aliens, before completing this form.
Specific Instructions
Step 1(c). Check your anticipated filing status. This will
determine the standard deduction and tax rates used to
compute your withholding.
Step 2. Use this step if you (1) have more than one job at the
same time, or (2) are married filing jointly and you and your
spouse both work.
Option (a) most accurately calculates the additional tax
you need to have withheld, while option (b) does so with a
little less accuracy.
If you (and your spouse) have a total of only two jobs, you
may instead check the box in option (c). The box must also be
checked on the Form W-4 for the other job. If the box is
checked, the standard deduction and tax brackets will be cut
in half for each job to calculate withholding. This option is
roughly accurate for jobs with similar pay; otherwise, more tax
than necessary may be withheld, and this extra amount will be
larger the greater the difference in pay is between the two jobs.
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. Step 3 of Form W-4 provides instructions for
determining the amount of the child tax credit and the credit
for other dependents that you may be able to claim when
you file your tax return. To qualify for the child tax credit, the
child must be under age 17 as of December 31, must be
your dependent who generally lives with you for more than
half the year, and must have the required social security
number. You may be able to claim a credit for other
dependents for whom a child tax credit can’t be claimed,
such as an older child or a qualifying relative. For additional
eligibility requirements for these credits, see Pub. 972, Child
Tax Credit and Credit for Other Dependents. You can also
include other tax credits in this step, such as education tax
credits and the foreign tax credit. To do so, add an estimate
of the amount for the year to your credits for dependents
and enter the total amount in Step 3. Including these credits
will increase your paycheck and reduce the amount of any
refund you may receive when you file your tax return.
Step 4 (optional).
Step 4(a). Enter in this step the total of your other
estimated income for the year, if any. You shouldn’t include
income from any jobs or self-employment. If you complete
Step 4(a), you likely won’t have to make estimated tax
payments for that income. If you prefer to pay estimated tax
rather than having tax on other income withheld from your
paycheck, see Form 1040-ES, Estimated Tax for Individuals.
Step 4(b). Enter in this step the amount from the Deductions
Worksheet, line 5, if you expect to claim deductions other than
the basic standard deduction on your 2020 tax return and
want to reduce your withholding to account for these
deductions. This includes both itemized deductions and other
deductions such as for student loan interest and IRAs.
Step 4(c). Enter in this step any additional tax you want
withheld from your pay each pay period, including any
amounts from the Multiple Jobs Worksheet, line 4. Entering an
amount here will reduce your paycheck and will either increase
your refund or reduce any amount of tax that you owe.
!
CAUTION
Page 3
Form W-4 (2020)
{
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1
Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one
job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the
“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter
that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $
2
Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and
2c below. Otherwise, skip to line 3.
a
Find the amount from the appropriate table on page 4 using the annual wages from the highest
paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job
in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries
and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a $
b
Add the annual wages of the two highest paying jobs from line 2a together and use the total as the
wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower
Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount
on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b $
c
Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c $
3
Enter the number of pay periods per year for the highest paying job. For example, if that job pays
weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3
4
Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this
amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional
amount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $
1
Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such
deductions may include qualifying home mortgage interest, charitable contributions, state and local
taxes (up to $10,000), and medical expenses in excess of 10% of your income . . . . . . . . 1 $
$24,800 if you’re married filing jointly or qualifying widow(er)
2
Enter:
$18,650 if you’re head of household
}
. . . . . . . . 2 $
$12,400 if you’re single or married filing separately
3
If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter -0- . .
3
$
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other
adjustments (from Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information . . .
4
$
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . .
5
$
Privacy Act and Paperwork Reduction Act Notice. We ask for the information
on this form to carry out the Internal Revenue laws of the United States. Internal
Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to
provide this information; your employer uses it to determine your federal income
tax withholding. Failure to provide a properly completed form will result in your
being treated as a single person with no other entries on the form; providing
fraudulent information may subject you to penalties. Routine uses of this
information include giving it to the Department of Justice for civil and criminal
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and
possessions for use in administering their tax laws; and to the Department of
Health and Human Services for use in the National Directory of New Hires. We
may also disclose this information to other countries under a tax treaty, to federal
and state agencies to enforce federal nontax criminal laws, or to federal law
enforcement and intelligence agencies to combat terrorism.
You are not required to provide the information requested on a form that is
subject to the Paperwork Reduction Act unless the form displays a valid OMB
control number. Books or records relating to a form or its instructions must be
retained as long as their contents may become material in the administration of
any Internal Revenue law. Generally, tax returns and return information are
confidential, as required by Code section 6103.
The average time and expenses required to complete and file this form will vary
depending on individual circumstances. For estimated averages, see the
instructions for your income tax return.
If you have suggestions for making this form simpler, we would be happy to hear
from you. See the instructions for your income tax return.
Step 4(b)Deductions Worksheet (Keep for your records.)
Step 2(b)Multiple Jobs Worksheet (Keep for your records.)
Page 4
Form W-4 (2020)
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 -
9,999
$0
$220
$850
$900
$1,020
$1,020
$1,020
$1,020
$1,020
$1,210
$1,870
$1,870
$10,000 - 19,999
220
1,220
1,900
2,100
2,220
2,220
2,220
2,220
2,410
3,410
4,070
4,070
$20,000 - 29,999
850
1,900
2,730
2,930
3,050
3,050
3,050
3,240
4,240
5,240
5,900
5,900
$30,000 - 39,999
900
2,100
2,930
3,130
3,250
3,250
3,440
4,440
5,440
6,440
7,100
7,100
$40,000 - 49,999
1,020
2,220
3,050
3,250
3,370
3,570
4,570
5,570
6,570
7,570
8,220
8,220
$50,000 - 59,999
1,020
2,220
3,050
3,250
3,570
4,570
5,570
6,570
7,570
8,570
9,220
9,220
$60,000 - 69,999
1,020
2,220
3,050
3,440
4,570
5,570
6,570
7,570
8,570
9,570
10,220
10,220
$70,000 - 79,999
1,020
2,220
3,240
4,440
5,570
6,570
7,570
8,570
9,570
10,570
11,220
11,240
$80,000 - 99,999
1,060
3,260
5,090
6,290
7,420
8,420
9,420
10,420
11,420
12,420
13,260
13,460
$100,000 - 149,999
1,870
4,070
5,900
7,100
8,220
9,320
10,520
11,720
12,920
14,120
14,980
15,180
$150,000 - 239,999
2,040
4,440
6,470
7,870
9,190
10,390
11,590
12,790
13,990
15,190
16,050
16,250
$240,000 - 259,999
2,040
4,440
6,470
7,870
9,190
10,390
11,590
12,790
13,990
15,520
17,170
18,170
$260,000 - 279,999
2,040
4,440
6,470
7,870
9,190
10,390
11,590
13,120
15,120
17,120
18,770
19,770
$280,000 - 299,999
2,040
4,440
6,470
7,870
9,190
10,720
12,720
14,720
16,720
18,720
20,370
21,370
$300,000 - 319,999
2,040
4,440
6,470
8,200
10,320
12,320
14,320
16,320
18,320
20,320
21,970
22,970
$320,000 - 364,999
2,720
5,920
8,750
10,950
13,070
15,070
17,070
19,070
21,290
23,590
25,540
26,840
$365,000 - 524,999
2,970
6,470
9,600
12,100
14,530
16,830
19,130
21,430
23,730
26,030
27,980
29,280
$525,000 and over
3,140
6,840
10,170
12,870
15,500
18,000
20,500
23,000
25,500
28,000
30,150
31,650
Single or Married Filing Separately
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 -
9,999
$460
$940
$1,020
$1,020
$1,470
$1,870
$1,870
$1,870
$1,870
$2,040
$2,040
$2,040
$10,000 - 19,999
940
1,530
1,610
2,060
3,060
3,460
3,460
3,460
3,640
3,830
3,830
3,830
$20,000 - 29,999
1,020
1,610
2,130
3,130
4,130
4,540
4,540
4,720
4,920
5,110
5,110
5,110
$30,000 - 39,999
1,020
2,060
3,130
4,130
5,130
5,540
5,720
5,920
6,120
6,310
6,310
6,310
$40,000 - 59,999
1,870
3,460
4,540
5,540
6,690
7,290
7,490
7,690
7,890
8,080
8,080
8,080
$60,000 - 79,999
1,870
3,460
4,690
5,890
7,090
7,690
7,890
8,090
8,290
8,480
9,260
10,060
$80,000 - 99,999
2,020
3,810
5,090
6,290
7,490
8,090
8,290
8,490
9,470
10,460
11,260
12,060
$100,000 - 124,999
2,040
3,830
5,110
6,310
7,510
8,430
9,430
10,430
11,430
12,420
13,520
14,620
$125,000 - 149,999
2,040
3,830
5,110
7,030
9,030
10,430
11,430
12,580
13,880
15,170
16,270
17,370
$150,000 - 174,999
2,360
4,950
7,030
9,030
11,030
12,730
14,030
15,330
16,630
17,920
19,020
20,120
$175,000 - 199,999
2,720
5,310
7,540
9,840
12,140
13,840
15,140
16,440
17,740
19,030
20,130
21,230
$200,000 - 249,999
2,970
5,860
8,240
10,540
12,840
14,540
15,840
17,140
18,440
19,730
20,830
21,930
$250,000 - 399,999
2,970
5,860
8,240
10,540
12,840
14,540
15,840
17,140
18,440
19,730
20,830
21,930
$400,000 - 449,999
2,970
5,860
8,240
10,540
12,840
14,540
15,840
17,140
18,450
19,940
21,240
22,540
$450,000 and over
3,140
6,230
8,810
11,310
13,810
15,710
17,210
18,710
20,210
21,700
23,000
24,300
Head of Household
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 -
9,999
$0
$830
$930
$1,020
$1,020
$1,020
$1,480
$1,870
$1,870
$1,930
$2,040
$2,040
$10,000 - 19,999
830
1,920
2,130
2,220
2,220
2,680
3,680
4,070
4,130
4,330
4,440
4,440
$20,000 - 29,999
930
2,130
2,350
2,430
2,900
3,900
4,900
5,340
5,540
5,740
5,850
5,850
$30,000 - 39,999
1,020
2,220
2,430
2,980
3,980
4,980
6,040
6,630
6,830
7,030
7,140
7,140
$40,000 - 59,999
1,020
2,530
3,750
4,830
5,860
7,060
8,260
8,850
9,050
9,250
9,360
9,360
$60,000 - 79,999
1,870
4,070
5,310
6,600
7,800
9,000
10,200
10,780
10,980
11,180
11,580
12,380
$80,000 - 99,999
1,900
4,300
5,710
7,000
8,200
9,400
10,600
11,180
11,670
12,670
13,580
14,380
$100,000 - 124,999
2,040
4,440
5,850
7,140
8,340
9,540
11,360
12,750
13,750
14,750
15,770
16,870
$125,000 - 149,999
2,040
4,440
5,850
7,360
9,360
11,360
13,360
14,750
16,010
17,310
18,520
19,620
$150,000 - 174,999
2,040
5,060
7,280
9,360
11,360
13,480
15,780
17,460
18,760
20,060
21,270
22,370
$175,000 - 199,999
2,720
5,920
8,130
10,480
12,780
15,080
17,380
19,070
20,370
21,670
22,880
23,980
$200,000 - 249,999
2,970
6,470
8,990
11,370
13,670
15,970
18,270
19,960
21,260
22,560
23,770
24,870
$250,000 - 349,999
2,970
6,470
8,990
11,370
13,670
15,970
18,270
19,960
21,260
22,560
23,770
24,870
$350,000 - 449,999
2,970
6,470
8,990
11,370
13,670
15,970
18,270
19,960
21,260
22,560
23,900
25,200
$450,000 and over
3,140
6,840
9,560
12,140
14,640
17,140
19,640
21,530
23,030
24,530
25,940
27,240
Employee Name: _________________________
Emplo
yee ID: ____________________________
Effective Date: ______________
Phone: ___________________
BANK INFORMATION
Deposit Priority (2) Deducts this amount 2nd
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ ____________
Bank Transit/Routing# (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________ Checking Savings
Deposit Priority (3) – Deducts this amount 3rd
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ ____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________
Checking Savings
Deposit Priority (4) – Deducts this amount 4th
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ ____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: ______________________
Bank Name: ___________________________________ Checking Savings
Deposit Priority (5) – Deducts this amount 5th
Allow Partial Deduction
Full Deposit or Balance
New Delete Change New Amount $ _____________
Bank Transit/Routing # (9 digits): ____________________ Account Number: ____________________
Bank Name: ___________________________________ Checking Savings
I herby authorize the City of Brockton to deposit my net pay as indicated above at the financial institution(s) named above. I understand and agree
to hold the above named financial institution(s) harmless for any erroneous deposits or adjustments not caused by the financial institution.
It is understood that I may terminate this agreement at any time by written notification to the Human Resources Department. Any such notification
to the City shall be effective only with respect to entries initiated by the City after receipt of such notification and reasonable opportunity to act
upon it.
EMPLOYEE SIGNATURE: ____________________________________________ DATE: ______________________
CITY OF BROCKTON
Deposit Priority (1) – Deducts this amount 1st
Allow Partial Deduction
Full Deposit or Balance
Bank Transit/Routing# (9 digits): ____________________ Account Number: _____________________
Bank Name: ___________________________________ Checking Savings
New Delete
Change New Amount $ ____________
AUTHORIZATION AGREEMENT FOR EMPLOYEE DIRECT PAYROLL DEPOSIT
Please note: Regarding "Full Deposit or Balance" - Only One Box can be checked
Social Security Administration
Statement Concerning Your Employment in a Job
Not Covered by Social Security
Employee Name Employee ID#
Employer Name Employer ID#
Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled,
you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit
from Social Security based on either your own work or the work of your husband or wife, or former husband or
wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits,
however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit
amount may be affected.
Windfall Elimination Provision
Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a
modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax.
As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this
job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as
a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not
totally eliminate, your Social Security benefit. For additional information, please refer to Social Security
Publication, “Windfall Elimination Provision.”
Government Pension Offset Provision
Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you
become entitled will be offset if you also receive a Federal, State or local government pension based on work
where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or
widow(er) benefit by two-thirds of the amount of your pension.
For example, if you get a monthly pension of $600 based on earnings that are not covered under Social
Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If
you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 -
$400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security
benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security
Publication, “Government Pension Offset.”
For More Information
Social Security publications and additional information, including information about exceptions to each
provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf
or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.
I certify that I have received Form SSA-1945 that contains information about the possible effects of the
Windfall Elimination Provision and the Government Pension Offset Provision on my potential future
Social Security Benefits.
Signature of Employee
Date
Form SSA-1945 (01-2013)
Destroy Prior Editions
Information about Social Security Form SSA-1945 Statement Concerning Your
Employment in a Job Not Covered by Social Security
New legislation [Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires
State and local government employers to provide a statement to employees hired January 1, 2005 or later in a
job not covered under Social Security. The statement explains how a pension from that job could affect future
Social Security benefits to which they may become entitled.
Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is
the document that employers should use to meet the requirements of the law. The SSA-1945 explains the
potential effects of two provisions in the Social Security law for workers who also receive a pension based on
their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a
worker’s Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a
Social Security benefit received as a spouse, surviving spouse, or an ex-spouse.
Employers must:
Give the statement to the employee prior to the start of employment;
Get the employee’s signature on the form; and
Submit a copy of the signed form to the pension paying agency.
Social Security will not be setting any additional guidelines for the use of this form.
Copies of the SSA-1945 are available online at the Social Security website,
www.socialsecurity.gov/online/ssa-1945.pdf. Paper copies can be requested by email at
ofsm.oswm.rqct.orders@ssa.gov or by fax at 410-965-2037. The request must include the name, complete
address and telephone number of the employer. Forms will not be sent to a post office box. Also, if
appropriate, include the name of the person to whom the forms are to be delivered. The forms are available in
packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.
Form SSA-1945 (01-2013)
Equal Opportunity Employment Self-Identify Data Form
The City of Brockton is an Equal Opportunity Employer with a commitment to recruitment and retention of a
diverse and inclusive community. Collection of the following information on gender, race/ethnicity, disability
and veteran status is in compliance with Federal laws and regulations, executive orders and applicable State
laws and regulations.
Anti-Discrimination Notice. It is an unlawful employment practice for an employer to fail or refuse to hire
or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s
terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin.
The information that you submit will remain confidential and be used by the City only for statistical and
required reporting purposes. Completion of this form is voluntary; failure to provide this information will not
adversely affect your employment and/or employment consideration.
Full Name: Date of Hire:
Department: Position Title:
Gender: Male Female I choose not to ID
ETHNICITY: Are you of Hispanic or Latino Origin? Yes No
(A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin,
regardless of race.)
RACE: Select one or more that apply:
American Indian or Alaskan Native
(Not Hispanic or Latino)
A person having origins in any of the original peoples of North
and South America (including Central America) and who
maintains tribal affiliation or community attachment.
Asian (Not Hispanic or Latino)
A person having origins in any of the original peoples of the
Far East, Southeast Asia, or the Indian subcontinent
including, for example, Bangladesh, Cambodia, China, India,
Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Sri
Lanka, Thailand, and Vietnam.
Black or African American
(Not Hispanic or Latino)
A person having origins in any of the black racial groups of
Africa.
Native Hawaiian or Other Pacific
Islander (Not Hispanic or Latino)
A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
White or Caucasian
(Not Hispanic or Latino)
A person having origins in any of the original peoples of Europe,
the Middle East, or North Africa.
I choose not to ID
Invitation to Voluntarily Self-Identify Veteran Status
We ask that you please consider completing this Invitation to Voluntarily Self-Identify Veteran Status to
help us fulfill our commitments to equal opportunity and affirmative action and to meet our obligations as a
government contractor under the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended
by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA).
“Protected veteran” categories are identified in VEVRAA. This statute requires Government contractors to
take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated
veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal
veterans. VEVRAA defines these classifications as follows:
Protected Veteran classifications are defined as follows:
A "disabled veteran" is one of the following:
a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or
who but for the receipt of military retired pay would be entitled to compensation) under laws
administered by the Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected
disability.
A "recently separated veteran" means any veteran during the three-year period beginning on the date of
such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the
U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a
campaign badge has been authorized under the laws administered by the Department of Defense.
An "Armed Forces service medal veteran" means a veteran who, while serving on active duty in the U.S.
military, ground, naval or air service, participated in a United States military operation for which an
Armed Forces service medal was awarded pursuant to Executive Order 12985.
Self-Identification:
Are you a protected veteran:
I am a protected veteran I am NOT a protected veteran I choose not to ID
How did you learn about the job for which you are applying? (Please limit your selection to
ONE)
1. Walk-In
3. Job Board __________________________
5. Other (Please indicate) _________________
2. City Employee
4. City of Brockton Website
_______________________________________ _________________
Signature Date
__________________________ __________________
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 1 of 2
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to
qualified people with disabilities
i
To help us measure how well we are doing, we are asking you to tell us if you
have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will
choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used
against you in any way.
If you already work for us, your answer will not be used against you in any way. Because a person may
become disabled at any time, we are required to ask all of our employees to update their information every five
years. You may voluntarily self-identify as having a disability on this form without fear of any punishment
because you did not identify as having a disability earlier.
.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that
substantially limits a major life activity, or if you have a history or record of such an impairment or medical
condition.
Disabilities include, but ar
e not limited to:
Blindness
Deafness
Cancer
Diabetes
Epilepsy
Autism
Cerebral palsy
HIV/AIDS
Schizophrenia
Muscular
dystrophy
Bipolar disorder
Major depression
Multiple sclerosis (MS)
Missing limbs or
partially missing limbs
Post-traumatic stress disorder (PTSD)
Obsessive compulsive disorder
Impairments requiring the use of a wheelchair
Intellectual disability (previously called mental
retardation)
Please check one of the boxes below:
YES, I HAVE A DISABILITY (or previously had a disability)
NO, I DON’T HAVE A DISABILITY
I DON’T WISH TO ANSWER
Your
Name
Tod
ay’s Date
i
Voluntary Self-Identification of Disability
Form CC-305
OMB Control Number 1250-0005
Expires 1/31/2020
Page 2 of 2
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities.
P
lease tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples
of reasonable accommodation include making a change to the application process or work procedures,
providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal
employ
ment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contract
Compliance Programs (OFCCP) website at
www.dol.gov/ofccp.
PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required
to respond to a collection of information unless such collection displays a valid OMB control number. This
survey should take about 5 minutes to complete.
EMPLOYMENT OF RELATIVES
DISCLOSURE STATEMENT
To all finalist applicants for employment with the City of Brockton:
It is the policy of the City of Brockton not to hire individuals for positions in city departments where
members of their “immediate family” are also employed.
It is the policy of the City of Brockton to regulate, restrict or prohibit the employment of” relatives” when
it may have a detrimental effect on supervision and moral, and when it is necessary for proper and efficient
operation and delivery of City services. This policy will follow, as a minimum, the standards set forth in the laws of
the Commonwealth of Massachusetts under MGL c 268A.
For purposes of this policy, “immediate family” shall be as defined in Massachusetts General Laws
Chapter 268A “the employee and his spouse, and their parents, children, brothers, and sisters.”
For the purposes of this policy, “relative” shall include parent (including stepparent or in-law);
grandparent (including step-grandparent); child (including in-law) grandchild; brother (including in-law and step or
half-brother); sister (including in-law and step or half-sister); uncle; aunt; cousin; niece; nephew; and any other
person, whether related or not, who resides in the same household as the employee.
Section One, applies to the position and department for which you have applied.
Section Two, applies to any relatives currently employed by the City of Brockton.
Please complete and sign the statement as part of your being considered for employment as a finalist for
a position within the City. Your signature will indicate that the information provided is true and complete to the
best of your knowledge.
SECTION ONE
I hereby certify that I am not an immediate family member (as defined above) of any active employee
within the City of Brockton _____________________________________Department.
______________________________ ______________________________
Name (Print) Name (Signature)
______________________________
Date
SECTION TWO
I hereby certify that I am an immediate family member (as defined above) and/or a relative of any active employee
within the City of Brockton _____________________________________Department.
NAME OF CITY EMPLOYEE DEPARTMENT
_______________________________ _____________________________
_______________________________ ______________________________
______________________________ ______________________________
Name (Print) Name (Signature)
City of Brockton
Human Resources
City of Champions
BROCKTON CITY HALL ■ 45 SCHOOL STREET ■ BROCKTON, MASSACHUSETTS 02301
TEL: (508) 580-7820 FAX: (508) 580-7133
personnel@cobma.us
ROBERT F. SULLIVAN
May
or
SANDRA KNIGHT
Director of Human Resources
MEMORANDUM
To: All Brockton City Employees and Affiliates
From: Sandra Knight, Director of Human Resources
Subject: Annual Notice Conflict of Interest Law Education Requirements
The conflict of interest law seeks to prevent conflicts between private interests and public duties,
foster integrity in public service, and promote the public's trust and confidence in that service by
placing restrictions on what employees of the university may do on the job, after hours, and after
leaving public service.
Conflict of interest law education and training is mandated by the City of Brockton and the
Commonwealth of Massachusetts, which requires that all employees and affiliates annually
complete the Acknowledgement Receipt of the Summary and every two (2) years for the online
training. Please note: New employees should complete the training within thirty (30) days of the
date of hire.
To ensure compliance with the Conflict of Interest requirements, please complete the following
steps:
1. Acknowledge Receipt of the Summary of the Conflict of Interest Law for Municipal
Employees:
The summary of the conflict of interest law, General Laws chapter 268A, is intended to
help employees understand how that law applies to them. The summary is not a substitute
for legal advice, nor does it mention every aspect of the law that may apply in a particular
situation.
I have attached a form for your convenience or you may also download the
acknowledgement form at: https://www.mass.gov/service-details/summary-of-the-
conflict-of-interest-law-for-municipal-employees. If needed, you may obtain a copy in
the Department of Human Resources.
2. Complete the Conflict of Interest Law Online Training Program:
The training program covers various issues you may encounter as a public employee and
provides examples and reference information to help you recognize conflicts of interest.
Recognizing and properly responding to a conflict of interest is a key element to
City of Brockton
Human Resources
City of Champions
BROCKTON CITY HALL ■ 45 SCHOOL STREET ■ BROCKTON, MASSACHUSETTS 02301
TEL: (508) 580-7820 FAX: (508) 580-7133
personnel@cobma.us
ROBERT F. SULLIVAN
May
or
SANDRA KNIGHT
Director of Human Resources
maintaining the public’s confidence in government and in the integrity of the work we do
as public employees.
The training program can be found at: https://www.mass.gov/how-to/complete-the-
online-training-program-for-municipal-employees
It should take approximately one (1) hour to complete.
Upon completion of the training you will have the ability to print a Certificate of Completion.
Please do so, make a copy for your records and send the certificate to Human Resources. You
must complete the entire training in order to receive a certificate. The Ethics Commission will
not have any records to verify that you completed the program.
If you completed the Online Training Program within a two year period, this requirement
does not apply to you.
NOTE: The online training program is not compatible with the Google Chrome web browser and
make sure to disable pop-up blockers.
If you have questions, please review the Education and Training Guidelines available on the
State Ethics Commission’s website, www.mass.gov/ethics. The guidelines provide helpful
information about who is required to comply with these statutory requirements, record-keeping
requirements, troubleshooting and the process.
Thank you for your time and attention to this important matter. If you have any questions, please
contact Human Resources at 508-580-7820 or personnel@cobma.us.
CITY OF BROCKTON
DEPARTMENT OF HUMAN RESOURCES
45 School Street Brockton, MA
Honorable, Mayor Robert F. Sullivan
Policy Name: NOTICE OF RESIDENCY ORDINANCE
Issuing Office: DEPARTMENT OF HUMAN RESOURCES
I, ___________________________________ (print name), herby acknowledge that, as a
condition of my employment with the City of Brockton, Section 2-110 of the Revised
Ordinances of the City of Brockton mandates that I shall be a resident of the City of Brockton or
shall, within one (1) year of my employment establish residency within the City.
I also acknowledge that, should I fail to comply with this ordinance, such non-compliance is
determined to be voluntary termination of my employment.
Further, I understand and will comply with the requirement that annually, on each July 1
following my employment, I will file with my Department Head or like officer, a certification,
signed under the pains and penalties of perjury, stating my name and place of residence.
Name:
Address:
_________________________________
(Print)
________________________________________________________________
Street City State Zip
Signature: ______________________________ Date: ______________________
(Enclosure)
CITY OF BROCKTON
DEPARTMENT OF HUMAN RESOURCES
45 School Street Brockton, MA
Honorable, Mayor Robert F. Sullivan
Sec. 2-110. - Residency requirement of employment and promotions.
Every person first employed by the City of Brockton on or after the first day of January, 1992,
shall be a resident of the city or shall, within one (1) year after such person commences to be
employed by the city, establish residency within the city.
For the purposes of this section, an employee shall be any person receiving monies from the
city subject to withholding taxes by the state or federal government.
All department heads reappointed by the city on or after the first day of January, 1992, shall
be, or within one (1) year of such reappointment, become a resident of the city as defined herein.
Failure to do so shall be determined to be a voluntary termination of employment.
Failure of an employee to establish residency within the City of Brockton within one (1) year
after commencement of employment with the city shall be determined to be a voluntary
termination of employment by such employee. A department head, upon hiring a new employee,
shall cause such employee to sign a form acknowledging the provisions of the residency ordinance.
Such form shall be filed by the department head with the city clerk and a copy of such form shall
be provided by the department head to the employee.
Upon taking employment with the city, and annually on July 1st thereafter, every person
subject to this section shall file with his or her department head, or like officer, a certificate signed
under the pains and penalties of perjury, stating his or her name and place of residence. Upon
receipt of a certificate indicating a place of residence not within the city, or if no such certificate
is filed, the department head or like officer shall give notice of his action to the city clerk, who
shall transmit the same to the city council, the mayor and the treasurer. No person so stricken from
a payroll shall be re-employed by the city for a period of one (1) year following the cessation of
his or her employment.
Any person, acting in behalf of the city who makes payment of wages to any person stricken
from a payroll under the provisions hereof, within one (1) year of the date of striking, and any
person accepting such payment, shall be punished by a fine of two dollars ($2.00) for each dollar
($1.00) so paid or accepted.
In the event that this section shall be deemed to be in conflict with a provision of any general
or special law, the provision of that general or special law shall govern and shall not defeat the
application of this section with respect to any position not governed by that law.
Applicants at the time of filing an application for employment by the city, shall not as a
condition of filing said application be required to be a resident of the city, provided further however
that, if said applicant is subsequently employed, said applicant-employee shall as a term and
condition of employment become a resident of the city and each such employee shall continue to
maintain residency in the city during his or her term of employment.
CITY OF BROCKTON
DEPARTMENT OF HUMAN RESOURCES
45 School Street Brockton, MA
Honorable, Mayor Robert F. Sullivan
All persons appointed to membership on boards and commissions of the city shall be residents
of the city during the term for which they are appointed.
The mayor, with the approval of the city council, is hereby authorized in his discretion, for
good cause shown, to permit any officer or employee of the city to remain in the employ of the
city without complying with the provisions hereof, where:
(1) The health of any officer or employee or of a member of their immediate family
necessitates residence outside the city limits;
(2) The nature of the employment is such as to require residence outside the city limits;
(3) Special circumstances exist justifying residence outside the city limits.
This section shall not apply to persons appointed to advisory committees established under
federal or state grant-in-aid programs except where otherwise specified.
The provisions hereof are severable, and the action of any court of competent jurisdiction in
declaring any part or portion hereof invalid, shall not act to defeat any remaining part or portion
hereof, and any such action declaring this section invalid with respect to any position or person
shall not be held to apply to any other person or position.
In construing this section, residence shall be the actual principal residence of the individual,
where he or she normally eats and sleeps and maintains his or her normal personal and household
effects. This section shall be deemed to affect both civil service and non-civil service employees
of the city.
(Ord. of 7-30-91; Ord. No. D357, 2-17-95)
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
1
CriminalOffenderRecordInformation(CORI)
AcknowledgementForm
TobeusedbyorganizationsconductingCORIchecksforemployment,volunteer,subcontr actor,licensing,andhousing
purposes.
_______________________________________________________________________________isregisteredunderthe
(Organization)
provisionsofM.G.L.c.6,§172toreceiveCORIforthepurposeofscreeningcurrentandotherwisequalifiedprospective
employees, subcontractors, volunteers, license appli cants, current licensees, and applica nts for the rental or lease of
housing.
Asaprospectiveorcurrentemployee,subcontractor,volunteer,license
applicant,currentlicensee,orapplicantforthe
rentalorleaseofhousing,Iun derstandthataCORIcheckwillbesubmittedformypersonalinformationtotheDCJIS.I
herebyacknowledgeand providepermissionto__________________________________________________________
(Organization)
to submit a CORI check for my information to the DCJIS. This authorization
is valid for one year from the date of my
signature.Imaywithdrawthisauthorizationatanytimebyproviding _________________________________________
(Organization)
withwrittennoticeofmyintenttowithdrawconsenttoaCORIcheck.
FOREMPLOYMENT,VOLUNTEER,ANDLICENSINGPURPOSESONLY:
The_______________________________________________________________________________mayconduct
(Organization)
subsequentCORI
checkswithinoneyearofthedatethisFormwassignedbyme,provided,however,that
_______________________________________________________________________________,mustfirstprovideme
(Organization)
withwrittennoticeofthischeck.
By signing below, I provide my conse nt to a CORI check and affirm that the information provided on Page 2 of
this
AcknowledgementFormistrueand accurate.
___________________________________________________________ _________________________________
SignatureofCORISubject Date

The City of Brockton
The City of Brockton
The City of Brockton
The City of Brockton
The City of Brockton
THE COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF PUBLIC SAFETY AND SECURITY
Department of Criminal Justice Information Services
200 Arlington Street, Suite 2200, Chelsea, MA 02150
TEL: 617-660-4640 | TTY: 617-660-4606 | FAX: 617-660-5973
MASS.GOV/CJIS
2
SUBJECTINFORMATION
PleasecompletethissectionusingtheinformationofthepersonwhoseCORIyouarerequesting.
Thefieldsmarkedwithanasterisk(*)arerequiredfields.
* FirstName:________________________________________________________ MiddleInitial: _________________
* LastName:_________________________________________________________ Suffix(Jr.,Sr.,etc.): _____________
FormerLastName1: _______________________________________________________________________________
FormerLastName2: _______________________________________________________________________________
FormerLastName3: _______________________________________________________________________________
FormerLastName4: _______________________________________________________________________________
* DateofBirth(MM/DD/YYYY): ___________________ PlaceofBirth:________________________________________
* LastSIXdigitsofSocialSecurityNumber: ______‐‐____________ NoSocialSecurityNumber
Sex: _________________ Height: _____ft. _____in. EyeColor: _______________ Race: ______________________
Driver’sLicenseorIDNumber:______________________________________ StateofIssue:____________________
Father’sFullName: ________________________________________________________________________________
Mother’sFullName: _______________________________________________________________________________
CurrentAddress
* StreetAddress:____________________________________________________________________________________
Apt.#orSuite: _____________ *City:__________________________ *State: ________ *Zip:_______________
SUBJECTVERIFICATION
Theaboveinformationwasverifiedbyreviewingthefollowingform(s)ofgovernmentissuedidentification:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Verifiedby:
___________________________________________________________
PrintNameofVerifyingEmployee
___________________________________________________________ _________________________________
SignatureofVerifyingEmployee Date
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome