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USCIS

Form I-9

OMB No. 1615-0047

Expires 10/31/2022

Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019

Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,

during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an

employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the

documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later

than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

Employee's E-mail Address

Employee's Telephone Number

U.S. Social Security Number

1. A citizen of the United States

2. A noncitizen national of the United States (See instructions)

3. A lawful permanent resident

4. An alien authorized to work until

(See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in

connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

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.

claim for federal income tax purposes. You

also will receive additional allowances if

you or your spouse are age 65 or older, or

if you or your spouse are legally blind.

How do I ﬁgure the correct

number of allowances?

Complete the worksheet on the back of

this page to ﬁgure the correct number

of allowances you are entitled to claim.

Give your completed Form IL-W-4 to your

employer. Keep the worksheet for your

records.

If you have more than one job or

your spouse works, you should ﬁgure the

total number of allowances you are en-

titled to claim. Your withholding usually will

be more accurate if you claim all of your

allowances on the Form IL-W-4 for the

highest-paying job and claim zero on all of

your other IL-W-4 forms.

What if I underpay my tax?

If the amount withheld from your com-

pensation is not enough to cover your

tax liability for the year, (e.g., you have

non-wage income, such as interest or

dividends), you may reduce the number of

allowances or request that your employer

withhold an additional amount from your

pay. Otherwise, you may owe additional

tax at the end of the year. If you do not

have enough tax withheld from your pay,

and you owe more than $500 tax at the

end of the year, you may owe a late-pay-

ment penalty. You should either increase

the amount you have withheld from your

pay, or you must make estimated tax pay-

ments.

You may be assessed a late‑payment

penalty if your required estimated pay-

ments are not paid in full by the due dates.

You may still owe this penalty for an

earlier quarter, even if you pay enough tax

later to make up the underpayment from a

previous quarter.

For additional information on penalties,

see Publication 103, Uniform Penal-

ties and Interest. Visit our website at

tax.illinois.gov to obtain a copy.

Where do I get help?

• Visitourwebsiteattax.illinois.gov

• CallourTaxpayerAssistanceDivision

at 1 800 732‑8866 or 217 782‑3336

• CallourTDD(telecommunications

device for the deaf) at 1 800 544‑5304

• Writeto

ILLINOIS DEPARTMENT OF REVENUE

PO BOX 19044

SPRINGFIELD IL 62794‑9044

Illinois Department of Revenue

Form IL‑W‑4

Employee’s Illinois Withholding Allowance

Certiﬁcate and Instructions

IL-W-4 (R-5/12)

Who must complete Form IL‑W‑4?

If you are an employee, you must com-

plete this form so your employer can with-

hold the correct amount of Illinois Income

Taxfromyourpay.Theamountwithheld

from your pay depends, in part, on the

number of allowances you claim on this

form.

Even if you claimed exemption from

withholding on your federal Form W-4,

U.S.Employee’sWithholdingAllowance

Certiﬁcate, because you do not expect

to owe any federal income tax, you may

berequiredtohaveIllinoisIncomeTax

withheld from your pay (see Publication

130, Who is Required to Withhold Illinois

IncomeTax).Ifyouareclaimingexempt

status from Illinois withholding, you must

check the exempt status box on Form

IL-W-4 and sign and date the certiﬁcate.

DonotcompleteLines1through3.

If you are a resident of Iowa, Kentucky,

Michigan, or Wisconsin, or a military

spouse, see Form W-5-NR, Employees

Statement of Nonresidence in Illinois, to

determine if you are exempt.

If you do not ﬁle a completed Form

IL-W-4 with your employer, if you fail to

sign the form or to include all necessary

information, or if you alter the form, your

employermustwithholdIllinoisIncomeTax

on the entire amount of your compensa-

tion, without allowing any exemptions.

When must I ﬁle?

You must ﬁle Form IL-W-4 when Illinois

IncomeTaxisrequiredtobewithheldfrom

compensation that you receive as an em-

ployee. You should complete this form and

give it to your employer on or before the

date you start working for your employer.

You may ﬁle a new Form IL-W-4 any time

your withholding allowances increase. If

the number of your previously claimed al-

lowances decreases, you must ﬁle a new

Form IL-W-4 within 10 days. However, the

death of a spouse or a dependent does

not affect your withholding allowances until

the next tax year.

When does my Form IL‑W‑4

take effect?

If you do not already have a Form IL-W-4

on ﬁle with your employer, this form will be

effective for the ﬁrst payment of compen-

sation made to you after this form is ﬁled.

If you already have a Form IL-W-4 on ﬁle

with this employer, your employer may

allow any change you ﬁle on this form to

become effective immediately, but is not

required by law to change your withhold-

ing until the ﬁrst payment of compensation

is made to you after the ﬁrst day of the

next calendar quarter (that is, January 1,

April1,July1,orOctober1)thatfallsat

least 30 days after the date you ﬁle the

change with your employer.

Example: If you have a baby and ﬁle a

new Form IL-W-4 with your employer to

claim an additional exemption for the baby,

your employer may immediately change

the withholding for all future payments of

compensation. However, if you ﬁle the new

form on September 1, your employer does

not have to change your withholding until

the ﬁrst payment of compensation is made

to you after October 1. If you ﬁle the new

form on September 2, your employer does

not have to change your withholding until

the ﬁrst payment of compensation made to

youafterDecember31.

How long is Form IL‑W‑4 valid?

Your Form IL-W-4 remains valid until a

new form you have ﬁled takes effect or

until your employer is required by the

department to disregard it. Your employer

is required to disregard your Form IL-W-4

if you claim total exemption from Illinois

IncomeTaxwithholding,butyouhavenot

ﬁled a federal Form W-4 claiming total

exemption.Also,iftheInternalRevenue

Service (IRS) has instructed your em-

ployer to disregard your federal Form W-4,

your employer must also disregard your

Form IL-W-4. Finally, if you claim 15 or

more exemptions on your Form IL-W-4

without claiming at least the same number

of exemptions on your federal Form W-4,

and your employer is not required to refer

your federal Form W-4 to the IRS for re-

view, your employer must refer your Form

IL-W-4 to the department for review. In that

case, your Form IL-W-4 will be effective

unless and until the department notiﬁes

your employer to disregard it.

What is an “exemption”?

An“exemption”isadollaramounton

which you do not have to pay Illinois

IncomeTax.Therefore,youremployerwill

withholdIllinoisIncomeTaxbasedonyour

compensation minus the exemptions to

which you are entitled.

What is an “allowance”?

Thedollaramountthatisexemptfrom

IllinoisIncomeTaxisbasedonthenumber

ofallowancesyouclaimonthisform.As

an employee, you receive one allowance

unless you are claimed as a dependent on

another person’s tax return (e.g., your par-

ents claim you as a dependent on their tax

return). If you are married, you may claim

additional allowances for your spouse and

any dependents that you are entitled to

Use your mouse or Tab key to move through the fields. Use your mouse or space bar to enable check boxes.

Illinois Withholding Allowance Worksheet

Step 1: Figure your basic personal allowances (including allowances for dependents)

Check all that apply:

No one else can claim me as a dependent.

I can claim my spouse as a dependent.

1 Write the total number of boxes you checked. 1 _______________

2 Write the number of dependents (other than you or your spouse) you will claim on your tax return. 2 _______________

3 AddLines1and2.Writetheresult.Thisisthetotalnumberofbasicpersonalallowancestowhich   

you are entitled. 3 _______________

4 IfyouwanttohaveadditionalIllinoisIncomeTaxwithheldfromyourpay,youmayreducethe   

number of basic personal allowances or have an additional amount withheld. Write the total number

of basic personal allowances you elect to claim on Line 4 and on Form IL-W-4, Line 1. 4 _______________

Step 2: Figure your additional allowances

Check all that apply:

I am 65 or older. I am legally blind.

My spouse is 65 or older. My spouse is legally blind.

5 Write the total number of boxes you checked. 5 _______________

6 WriteanyamountthatyoureportedonLine4oftheDeductionsandAdjustmentsWorksheet   

for federal Form W-4. 6 _______________

7 DivideLine6by1,000.Roundtothenearestwholenumber.WritetheresultonLine7. 7 _______________

8 AddLines5and7.Writetheresult.Thisisthetotalnumberofadditionalallowancestowhich   

you are entitled. 8 _______________

9 IfyouwanttohaveadditionalIllinoisIncomeTaxwithheldfromyourpay,youmayreducethe   

number of additional allowances or have an additional amount withheld. Write the total number

of additional allowances you elect to claim on Line 9 and on Form IL-W-4, Line 2. 9 _______________

Ifyouhavenon-wageincomeandyouexpecttooweIllinoisIncomeTaxonthatincome,youmaychoosetohaveanadditional

amount withheld from your pay. On Line 3 of Form IL-W-4, write the additional amount you want your employer to withhold.

Cut here and give the certiﬁcate to your employer. Keep the top portion for your records.

General Information

Complete this worksheet to ﬁgure your total withholding

allowances.

Everyone must complete Step 1.

Complete Step 2 if

 • you(oryourspouse)areage65orolderorlegallyblind,or

 • youwroteanamountonLine4oftheDeductionsand 

 AdjustmentsWorksheetforfederalFormW-4.

Illinois Department of Revenue

IL‑W‑4 Employee’s Illinois Withholding Allowance Certiﬁcate

____ ____ ____ - ____ ____ - ____ ____ ____ ____

Social Security number

________________________________________________________________________

Name

________________________________________________________________________

Street address

________________________________________________________________________

City State ZIP

Check the box if you are exempt from federal and Illinois

IncomeTaxwithholdingandsignanddatethecerticate.

IL-W-4 (R-5/12)

If you have more than one job or your spouse works, you should

ﬁgure the total number of allowances you are entitled to claim.

Your withholding usually will be more accurate if you claim all of

your allowances on the Form IL-W-4 for the highest-paying job and

claim zero on all of your other IL-W-4 forms.

You may reduce the number of allowances or request that your

employer withhold an additional amount from your pay, which may

help avoid having too little tax withheld.

Employer: Keep this certiﬁcate with your records. If you have referred the employee’s federal

certiﬁcate to the IRS and the IRS has notiﬁed you to disregard it, you may also be required to

disregard this certiﬁcate. Even if you are not required to refer the employee’s federal certiﬁcate to

theIRS,youstillmayberequiredtoreferthiscerticatetotheIllinoisDepartmentofRevenuefor

inspection.SeeIllinoisIncomeTaxRegulations86Ill.Adm.Code100.7110.

1 Write the total number of basic allowances that you

are claiming (Step 1, Line 4, of the worksheet). 1 ____________

2 Write the total number of additional allowances that

you are claiming (Step 2, Line 9, of the worksheet). 2 ____________

3 Write the additional amount you want withheld

(deducted) from each pay. 3 ____________

I certify that I am entitled to the number of withholding allowances claimed on

this certiﬁcate.

______________________________________________________________________

Yoursignature  Date

ThisformisauthorizedundertheIllinoisIncomeTaxAct.Disclosure

of this information is required. Failure to provide information may

result in this form not being processed and may result in a penalty.

Reset

P:\District Forms\Direct Deposit Authorization Form .doc

DIRECT DEPOSIT OF PAYROLL AUTHORIZATION FORM

Name _____________________________________________ ____________ ___________________

Last First Middle Initial Department Social Security #

CHECK APPLICABLE BOX

 NEW ENROLLMENT

Complete and sign this form. Attach a voided check for each account or a deposit slip if account does not use checks.

 CHANGE OF ACCOUNT AND/OR FINANCIAL INSTITUTION

Complete and sign this form. Attach a voided check for new checking account or deposit slip for new savings account.

 CANCEL PARTICIPATION

Sign Form

CHECK APPLICABLE BOX

 Checking  Savings  Credit Union

Financial Institution ___________________________________________________________________

City and State ________________________________________________________________________

Account # ________________________________________________

(If using a Credit Union, please verify your account number with your Credit Union.)

ATTACH VOIDED CHECK HERE

_____________________________________________________ ________________________

Employee Signature Date

RETURN COMPLETED FORM TO PAYROLL OFFICE

AUTHORIZATION STATEMENT

I hereby authorize Edwardsville CUSD #7 and the Financial Institution listed above to deposit my pay

electronically to my account each payday. If funds to which I am not entitled are deposited to my account I

authorize Edwardsville CUSD #7 to direct the Financial Institution to return said funds. This authority will

remain in effect until I have signed a new authorization, or upon termination of employment.

Member Information and

Beneficiary Designation Form

First Name Middle Initial Last Name Maiden Name

Member Social Security number

(Required for tax-reporting purposes.)

Date of birth

Gender Male

Female

Home telephone number

Street Address

Work telephone number

Extension

City

Cell phone number

State

Zip

Email address

Please select one:

I have included my proof of birth that is required to receive any future benefits from TRS. Acceptable proof of birth includes a

copy of the birth certificate, valid passport, valid driver’s license or other state-issued identification card.

My birth certificate is already on file with TRS.

Member of another Illinois public employee retirement system (specify system’s name)

By completing this form, a TRS member or annuitant designates beneficiaries to receive death benefits. Information provided on this

form will become part of the member’s permanent TRS record and will determine distribution of death and survivor benefits. This

designation revokes any prior designation. If this current designation is found to be invalid, the most recent designation on file with TRS

will remain in effect. Eligibility is determined by the survivor’s status at the time of the member’s death. Monthly survivor benefits can

be paid only to eligible dependent beneficiaries.*

If the automatic designation is selected, do not complete the Beneficiary Refund or Survivor Benefits sections.

Automatic Designation (commonly selected by members with a spouse or civil union partner and/or minor children)

In lieu of designating specific beneficiaries, I elect that my dependent beneficiaries, as determined at my death, receive a

beneficiary refund and/or survivor benefits. If no dependent beneficiary survives, benefits will be paid to my estate.

If automatic designation is not selected, you must complete the Beneficiary Refund section. Alternate beneficiaries will receive benefits

should primary beneficiaries predecease the member. When a beneficiary designation includes more than one person, the benefits are

divided equally among the living beneficiaries of that class (primary or alternate).

Beneficiary Refund

Survivor Benefits

Primary Beneficiaries

First name

Last

Date of birth Relationship

First name

Last

Date of birth Relationship

First name

Alternate Beneficiaries

Last

Date of birth

Relationship

First name

Alternate Beneficiaries

Last

Date of birth

Relationship

If additional space is required, attach a separate sheet designating primary and alternate persons for Beneficiary Refund and Survivor

Benefits. Also include the last four digits of your Social Security number, signature, and date.

Certification: By signing, I certify that this information is correct. I am aware that pursuant to the Illinois Pension Code, 40 ILCS 5/1-135,

any person who knowingly makes any false statement or falsifies or permits to be falsified any record in an attempt to defraud the

Teachers’ Retirement System is guilty of a Class 3 felony. Please be advised that, if the TRS Board has reasonable suspicion that a false

record has been filed with the System, it is required to report the matter to the state’s attorney for investigation.

Member’s signature (mandatory)

Date

Signature pursuant to a General Power of Attorney is not accepted by TRS. *See page 2 for more information.

You may fax the form to TRS at (217) 787-2269

https://www.trsil.org/MIBD_form page 1 14006015 Online form 8/17

Types of Beneficiaries

The member may designate a beneficiary to receive survivor benefits. If this individual is a dependent beneficiary, then

he or she is eligible to receive either monthly benefits or a lump-sum payment. However, if the member designates a

nondependent beneficiary, only a lump-sum benefit is payable. Monthly benefits cannot be paid to dependent

beneficiaries if a nondependent beneficiary is also designated and survives the member.

Dependent beneficiary. A spouse to whom the member has been married for at least one year, except where a child is

born of the marriage in which case the qualifying period is not applicable; a civil union partner to whom the member has

been partnered for at least one year; an unmarried natural or adopted child under 18, or between ages 18 and 22 if he or

she is a full-time student in an accredited educational institution, or an unmarried child of any age who is dependent by

reason of a physical or mental disability and claimed as a dependent on the member’s final federal income tax return; a

dependent parent who received from the member at least half of his or her support for the 12-month period immediately

prior to the member’s death.

Nondependent beneficiary. Any other designated person or entity who is not a dependent beneficiary.

Types of Benefits

Beneficiary Refund. This benefit is only payable upon death. The member cannot elect to receive this benefit. This

refund includes a return of the member’s retirement contributions, statutorily required interest on the retirement

contributions, and member contributions paid toward the annual increases in annuity. This refund is payable: to a

designated beneficiary; if no beneficiary is designated, to the surviving spouse or civil union partner; or if no one is

designated and there is no surviving spouse or civil union partner, to the member's estate. After retirement, this amount

is reduced by the amount of retirement benefit payments made to the member.

Survivor Benefits. A beneficiary is eligible to receive a lump-sum survivor benefit if the member’s death occurs during

TRS-covered employment or in the 12-month period immediately following the last day of earnings, while on a

creditable leave of absence, or while receiving disability benefits.

A dependent beneficiary may also be eligible to receive monthly survivor benefits if certain requirements are met by the

member before death.

Children, unless named as a beneficiary on the MIBD form, are only eligible for benefits if they are the children of the

surviving parent who will receive monthly benefits. In the case of a divorce, if the member names the new spouse or

civil union partner and had children with the prior spouse or civil union partner, those children are not eligible for

monthly survivor benefits.

For instructions on designating a trust, please contact TRS.

A Qualified Illinois Domestic Relations Order (QILDRO) on file with TRS when the member dies may affect

distribution of survivor benefits. For more information about QILDROs, please consult the QILDRO publication

available on the TRS website.

As with all TRS benefits, death and survivor benefits must be paid in accordance with the Pension Code,

40 ILCS 5/16. If there is any discrepancy between the information on this form and applicable law, the law controls.

Page 2

TO: All Staff Members

FROM: Adam Garrett, Assistant Superintendent of Personnel

RE: Changes in Board Policies

The Board of Education adopted changes to the district’s Drug Free Workplace and No Smoking

policies. These changes may be summarized as follows:

Drug Free Workplace Policy

Strengthens and clarifies the district’s ban on alcohol and illegal substances on district

property or at student activities.

No Smoking Policy

Brings the district into compliance with state/federal laws, which ban the use of tobacco

products on school property.

These policies are so critical that we feel that all employees should read them in their entirety.

For that reason we have attached a copy of each policy to this document. All employees should

read these attached documents, and sign the statement below attesting that they have indeed

received and read these policies. The signed statement should be returned to your supervisor.

As always, we appreciate your cooperation. Please feel free to contact your principal or myself it

you have questions about these policies.

I hereby attest that I have received and read a copy of the district’s revised board policies on

Drug Free Workplace and No Smoking.

__________________________________ _____________________ _____________

Signature of Employee Building Date

Date:______________ EMPLOYMENT PHYSICAL

Employee’s Name _________________________________________________ Date of Birth: _________________

Address___________________________________________________________________________________________

Street City State Zip

Weight ___________________________ Allergy ___________________________

Height ___________________________ Blood Pressure ___________________________

Skin ___________________________ Thyroid ___________________________

Ears ___________________________ Lungs ___________________________

Eyes ___________________________ Heart ___________________________

Nose ___________________________ Throat ___________________________

Orthopedic ________________________ Breast ___________________________

Corrective Lenses _____Yes _____No Pelvic ___________________________

Urinalysis (Recommended) ____________________ Tetanus (recommended) _____________________

Proof of Mumps Immunity - REQUIRED

(To include one of the following: 2 doses of vaccination, lab evidence (Mumps titer), or documentation of physician-

diagnosed disease)

This is NOT a requirement for Substitute Teachers

Health Limitations ____________________________________________________________________________________________

Date _________________________ Physician’s Signature _____________________________________________________

(Type or print physician’s name)_________________________________________________________________________________

Address __________________________________________________________ City/State/Zip_______________________________

EXAM IS TO BE SUBMITTED TO THE DISTRICT BOARD OFFICE WITHIN 30 DAYS OF EMPLOYMENT

IF SUBSTITUTE TEACHER -- PHYSICAL IS REQUIRED BEFORE YOU BEGIN SUBBING – THANK YOU!

Regional Office of Education 41

Substitute Fingerprinting

Location: 157 North Main Street, Suite 438 Edwardsville, IL 62025

Phone: 618-296-4530

Location Note: You will find us in the Administration Building next to the Madison County Courthouse

Hours: Monday – Friday, 8:30 – 4:00pm

Cost: $42.00 cash

Note: You will receive your fingerprint results in the mail. The results can take up to sixty days. Once you receive

the results, you may take them to the school district.

First Name

Last Name

Middle Initial

Maiden Name/ Other Names Used

DOB

State of Birth

Address

City

State

Zip

Gender

Race

Eye Color

Hair Color

Height

Weight

Drivers License Number

State Issued

Phone Number

Applicant Verification and Authorization

I, the undersigned, hereby authorize the release of any criminal history record information that may exist regarding

me from any agency organization, institution, or entity having such information on file. I authorize the Regional

Office of Education in Madison County to capture and securely transmit my fingerprints to the Illinois State Police

and/or Federal Bureau of Investigations for the purpose of checking my criminal history record information. I further

understand that my fingerprints may be retained by the Illinois State Police and/or Federal Bureau of Investigation

pursuant to applicable statute.

If your fingerprints are AFIS unacceptable and reprinting is necessary to receive results, the customer may be

required to return to fingerprint. This must be done within 10 days of receiving the error notice or there will be a

reprint fee of $42.00.

Signature of Applicant

Signature Date

Office Use Only

Technician Signature:

Date:

Time:

Sex Offender and

Child Murder

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