Palmer Staffing Paperwork Instructions
Please review all forms carefully to ensure all necessary signatures/documents are present before returning.
Application Form- Please fill out completely and sign on last page.
Reference form- Please list (3) contacts that I can reach out to, to complete your file.
Please list former supervisors. (Do not include peers, co-workers, or relatives)
Confidentiality form- Please read carefully and sign. You do not have to worry about a
witness signature.
Temporary Assignment Questionnaire- Please list any previous assignments you have
completed.
Temporary Policy Sheet- Please read carefully and initial/sign document.
Direct Deposit (don’t worry about attaching a voided check, simply list your routing &
account numbers).
Notice of Hire & Acknowledgment of Wages form- Please fill out the highlighted segments
that I’ve indicated for you. ”Employee” section and your Signature in section 8.
I9 Verification form- Please fill out completely and sign. **Take a clear picture of any ID(s)
and send back** Please refer to “List of Acceptable Documents sheet” for possible
forms of ID.
W4 form-Please fill out and sign at the bottom.
State Taxes- Only fill out the state that is applicable to you.
Palmer Staffing Benefits and Family Leave Law 2020 information.
Please reach out to us if you have any questions! Phone: 202-464-1000. Email: admin@palmer-staffing.com.
I. CANDIDATE INFORMATION
Last Name (Please Print) First M.I. Date:
Home Phone Work Cell E-mail Address
Street Address Apt. #
City State Zip Code
II. SUPPORTING INFORMATION
Type of Employment: Salary Desired:
Temporary Temp-to-Hire Direct Temp/Hourly: Full Time/Salary:
Education: High School College Master’s JD Degree: GPA:
Are you a citizen of the U.S.? Yes No If no, are you authorized to work in the U.S.? Yes No
Types of Position interested in:
Are you able to commit to a full time permanent
position for a minimum of two years?
Yes No
1.
2.
If no, explain:
3.
Available Date: Do you have any time off scheduled in the next
year?
Preferred Hours
Willing to go to:
N. Va? Georgetown? DC? Metro Only
8:30-5:00 9:00-5:30 9:30-6:00
Yes Yes Yes Non-Metro (car)
No No No Both
Language Skills: Spanish
Read Other: Read Other: Read How did you hear about us?
Write Write Write
Speak Speak Speak
Please rate the following on a scale of 1-10 (1 poor, 10-excellent)
How well do you work for demanding people? How are your organizational skills? Your punctuality?
To avoid duplicating your job search, please list companies you have contacted on your own or through some other source:
Select your 5 greatest strengths:
Ability to prioritize Self-Motivated Follows Directions Positive Attitude Multitasking Punctuality
Client Interaction Team Player Detail-Oriented Initiative Reliability Organization Skills
Flexibility Customer Service Skills Computer Skills
Please check experience in the following software programs and how long you have worked with them:
COMPUTER SOFTWARE
MS Word Access PowerPoint Excel
Styles TOC TOA Outlook
CANDIDATE
A
PPLICATION FORM
SOFTWARE SKILLSIII.
LEGAL SOFTWARE
iManage LegalKEY Carpe Diem Kroll
Concordance Westlaw Relativity Ringtail
Summation LexisNexis CPI PATTSY
ACCOUNTING SOFTWARE
ADP Quickbooks Elite
Please list all other software programs and special skills or training:
IV. LEGAL SKILLS
Please check experience in the following software programs and level of expertise:
ADMINISTRATIVE SKILLS
Shorthand
Dictation Fast Notes Dictaphone
LEGAL SKILLS
Bluebooking
Cite Checking Shepardizing
Discovery
Document Production
Privilege Review
Privilege Log Trial Preparation Trial Experience
Document Coding
Bates Numbering
Foreign Filing
E-filing
Pleadings Index
Docketing
Please list all other software programs and special skills or training:
V. LEGAL EXPERIENCE
Areas of law you prefer or are interested in gaining experience in:
Areas of law you do not like?
Particular firms you are interested in?
Particular firms you are not interested in working for?
Firm size preference
Small Medium Large
Please check areas of law experience:
Med. Malpractice Administrative Litigation Patent
Intellectual Prop. Immigration Real Estate Energy
Labor/Employment Bankruptcy Construction Banking
Telecommunication Mergers/Acq. Trademark Tax
Corporate Estates/Trusts Food & Drug Health
Personal Injury Gov’t Contracts Antitrust Environmental
Other law areas:
VI. PREVIOUS EMPLOYMENT
Present/Last Position-please include salary information
Dates Employed
Position
Company/Firm Name
From (Mo./Yr.) To
Starting Salary Ending Salary Supervisor Address
Overtime Salary Next Raise Supervisor’s Position Phone Number
Were you terminated?
Reason for Leaving Number of People in Company/
Number Supervised
Type of Business
Yes No
Previous Position
Dates Employed
Position Company/Firm Name
From (Mo./Yr.) To
Starting Salary Ending Salary Supervisor Address
Overtime Salary Next Raise Supervisor’s Position Phone Number
Were you terminated?
Reason for Leaving Number of People in Company/
Number Supervised
Type of Business
Yes No
Previous Position
Dates Employed
Position Company/Firm Name
From (Mo./Yr.) To
Starting Salary Ending Salary Supervisor Address
Overtime Salary Next Raise Supervisor’s Position Phone Number
Were you terminated?
Reason for Leaving Number of People in Company/
Number Supervised
Type of Business
Yes No
VII. DISCLAIMER & SIGNATURE
PLEASE READ CAREFULLY
It is our policy to make referrals of employment candidates to employers based on merit only. Our selection process is not influenced by race, sex, religion, color, age, or national
origin. I agree to the policy of conducting background reference check and understand that under the Fair Credit Reporting Act I have the right to a disclosure of the nature and
substance of any background investigation.
Signature: Date:
Emergency Contact Information:
Contact Name: Phone: Relationship:
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signature
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REFERENCE REQUEST
Please provide the names of former supervisors who can provide information about
your work
ability and experience. Please do not include peers, co-workers, or relatives.
Reference 1:
Contact Name & Title
Company Name
Phone Number Email/Fax
Employed from to
Reference 2:
Contact Name & Title
Company Name
Phone Number Email/Fax
Employed from to
Reference 3:
Contact Name & Title
Company Name
Phone Number Email/Fax
Employed from to
I, (Applicant Name), authorize you to furnish Palmer
Staffing Services with my employment record and any additional information about my job
history and performance that may enable Palmer Staffing Services to determine my
employment qualifications. I hereby release both you and Palmer Staffing Services from any
and all liability for any damage that results from the disclosure of this information.
Applicant Signature
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signature
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I understand that as a temporary employee of Palmer, I shall be working on assignments at various
law firms, corporate legal departments and other companies where I will be privy to confidential
and privileged documents and information. I understand that such documents and information are
subject to attorney-client work product restrictions upon disclosure to others and are highly
confidential in nature.
I agree not to disclose any documents and information that I see or hear while working on an
assignment for a client firm to anyone outside of the principals and employees of that firm. I
further agree not to discuss this information with employees of the firm unless necessary to my job
performance or I am instructed to do so. I agree that I shall not use any information gained while
on assignment for my personal benefit or for the benefit of others.
I declare that I do not have any business interest or proprietary interest with any person or in any
business that would create a conflict of interest with respect to the work I shall perform for the law
firm or client of Palmer where I am to be assigned. I further declare that I shall not accept any
future assignment with any law firm or client of Palmer, if my work for the firm or client would
create a conflict of interest because of any business interest I shall then have, or any proprietary
interest I shall then have with any person or in any business.
_____________________________________ ______________________________
Signature Witness Signature
_____________________________________ ______________________________
Name Witness Name
______________________________
Title
_____________________________________ ______________________________
Date Date
CONFIDENTIALITY
AGREEMENT
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signature
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signature
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TEMPORARY ASSIGNMENT QUESTIONNAIRE
Name: ____________________________________ Date: _____
In order to avoid duplication we request a list of the DC Metro area law firms and companies where you
have worked in a contract or
temporary basis. (You do not need to list the actual employment agencies that
you contracted through.) Thank you.
Firm or Company Name
Approximate
Dates
Position Direct Report Pay Rate
Scale of 1-
10 – job
satisfaction
(10 best)
Welcome to
Palme
r. We are glad you have chosen to register with us! The right attitude is critical to having a
successful assignment and will carry over into a successful career. Please read through our policies and sign at the
end, any questions please ask your recruiter.
Time Sheets - All temporaries are employees of Palmer. You MUST completely and properly complete the PLS
timesheet for every assignment. Have your time sheet signed by your immediate supervisor at the firm. If you do not
sign up for direct deposit or clearly indicate where you would like the check mailed to, it will be sent to your home
address. Email or Fax your time sheet no later than Monday Noon for work completed the previous week to (703)
904-1891 or rbeckwith@plsdc.com. When totaling your hours for the day, round to the nearest quarter hour (.25, .5
or .75). We do not pay for lunch.
Pay Checks – Paychecks are processed on Mondays, provided the above requirements are met, and funds are
guaranteed in your possession by Thursdays.
Punctuality - It is very important to arrive on time to your assignment. Plan to arrive 10-15 minutes early on the
first day of a new assignment. Please always be prepared and allow for possible delays such as weather or traffic
and leave your home early.
Sickness or Late Arrival - It is critical to notify Palmer immediately if there is any type of problem that will delay
or prevent you from going to your assignment. You may contact Palmer at anytime of the day or night. WE ARE
ACCESSIBLE TO YOU AND THE CLIENT 24-HOURS. Normal business hours are Monday through Friday, 8:30
AM-5:30 PM with the exception of some holidays. When calling after business hours, please leave a complete
detailed voice-mail message including a phone number where you can be reached. If Palmer personnel are not
available, leave a message with complete details (running 15 minutes late, out all day but in tomorrow, etc.) and then
call the assignment directly. ALWAYS CALL PLS FIRST. There may be instances where Palmer may require
appropriate documentation verifying an emergency for unscheduled leave.
No Call/No Show Policy – If for any reason you are unable to show for work, it is important for you to contact
Palmer immediately. If you do not show for work and do not call Palmer informing us of your absence, it will be
considered abandonment of your job. We will not be able to work with you in the future except for situations where
you may be able to provide proof that you were unable to contact Palmer.
Overtime – Overtime pay begins at time-and-one-half after forty hours in one week. Prior to working any overtime,
it must be approved by your supervisor at the law firm or corporation. All overtime hours that have not been
authorized by the client will not be paid.
Lunch/Hours of Assignment – When you are contacted for an assignment by Palmer, you will be given
specific information including the address of the firm, a contact person and the exact hours and days you will be
working. Please remember that you are required to take a one-hour lunch/break each day of the assignment unless
you have been granted special authorization by the contact at the firm. Any changes to your scheduled hours must
also be pre-authorized by your immediate supervisor or your consultant at Palmer.
Ending Assignment Early – Even though your assignment is expected to last a certain amount of time, the
client may choose to end it earlier than expected. There may also be other circumstances where a client will close
their offices due to uncontrollable situations, which include but are not limited to inclement weather, bomb threats or
special functions. Palmer will not be responsible to pay you for any portion of the original assignment that you do not
work. As a temporary employee, you will only be paid for actual hours worked.
Initial ___________
TEM
PORARY POLICY SHEET
Communication Communication with your assignment is to be conducted through Palmer. Do not
communicate with your assignment directly unless cleared with a
Palmer personnel if it is regarding requesting time
off, scheduling job interviews other than on your lunch break, personal & work related problems, questioning when
an assignment will end or why an assignment is ending, chance of permanent hiring, etc.
Time Off (while on an assignment) – Once you have accepted a temporary assignment from Palmer, we
expect you to fulfill your commitment. If you cannot honor the length of the commitment stated to you when the
assignment was presented, please do not accept it. If you must take an entire day off, this should be arranged at
least one week in advance. Interviews, doctor appointments etc. should be arranged at least 48 hours in advance if
you require it to be scheduled at anytime other than on your lunch break.
Personal Calls - You should not make personal calls from your assignment, unless it is an emergency. No long
distance or collect calls are allowed. No pagers or cellular phones are to be used during working hours at your
assignment.
Dress - Appropriate business attire is mandatory at all times unless instructed otherwise by Palmer or your
assignment supervisor. Appropriate dress means tie and jacket for men, and dress, skirt or suit for women.
Business attire DOES NOT include sneakers, blue jeans, leggings, flip flop shoes, shorts, skorts, capri pants, logo t-
shirts or athletic wear. Hats are inappropriate to be worn indoors. Please use good judgment in choosing your
attire.
Change of Address - If you have moved, you must contact Palmer with your new address. We will not stop
payment on paychecks that have been sent to your old address when you failed to inform us of your new address. If
you move and do not update us with new address information, your W-2 form will be sent to the last address we
have listed in our office.
Completed Assignments - After you have completed or left an assignment, there must be no further contact
with the client or its employees. No further contact includes, but is not limited to phone calls, e-mail messages, mail,
fax or visitation. We ask that you do not return to the firm after an assignment has ended. Should you have any
questions or follow-up issues with the firm, your consultant at Palmer will contact the client.
Miscellaneous - Under no circumstances should a temporary on assignment ask anyone at the firm for money.
Do not decorate desks with personal items, i.e., pictures, radios, mirrors, heaters, etc. Palmer is not responsible for
personal items that cannot be retrieved after an assignment ends.
If Palmer is unable to bill a client due to the performance of a temporary or breaking of the above policies,
Palmer may elect to pay the temporary minimum wage.
Palmer is committed to providing equal opportunity employment. We do not discriminate in any aspect of employment on the basis of race, color,
national origin, sex, age, marital status, sexual orientation, family responsibility, disability or any other improper criterion. Palmer will not tolerate
unlawful harassment of any kind. Concerns about sexual harassment or equal employment opportunity should be raised with your consultant or
anyone in management, at Palmer. Any complaints will be investigated promptly. Confidentiality will be maintained to the extent practical and
appropriate under the circumstances. Palmer will not retaliate, nor will it tolerate any attempt at retaliation, against person who raised employment
discrimination or harassment concerns in good faith. Any Palmer employee found to have violated the company’s policy would be subject to
discipline up to and including termination.
I have read and understand the information listed above _____________________________ Date: ________
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signature
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AUTHORIZATION FOR DIRECT DEPOSIT EMPLOYEE FORM
This authorizes Palmer Staffing Services to send credit entries electronically or by any other commercially accepted
method, to my
account as indicated below. This authorizes the financial institution holding the Account to post all such
entries.
Employee Bank Name
Routing #
Account #
This authorization will be in effect until Palmer Staffing Services receives a written termination notice from
myself and has a reasonable opportunity to act on it.
Signature
Printed Name
Date
IMPORTANT: This document must be signed by employees requesting automatic deposit of paychecks and retained on file
by the employer. Employees must attach a voided check their accounts to help verify their account numbers and bank
routing numbers.
Employee: Please fill out and return to your employer. Employer: Please save for your files only.
TEMPORARY STAFFING FIRMS
NOTICE OF HIRE EMPLOYMENT STATUS
AND ACKNOWLEDGEMENT OF WAGE RATE(S)
Initial Interview Assignment Range of Dates able to work: _____/____/______ to _____/____/______
Notice of Hire (Check only one)
Company Name: ___________________________________
DBA: _____________________________________________
Permanent Address:__________________________________
Street Line 2:_____________________________________
City:__________ State:_______ Zip Code:___________
Mailing Address: Same as Permanent Address
_______________________________________________
Street Line 2:____________________________________
City:___________ State: _______Zip Code:____________
Phone: (_____) _________-_______________
Name of Client: _________________________________
DBA: __________________________________________
Physical Address: ________________________________
Street Line 2:___________________________________
City: ___________ State: _______ Zip Code: __________
Employee Name: _________________________________
Physical Address: ________________________________
Street Line 2:____________________________________
City: ___________ State: _______ Zip Code: _______________
Employee
Client Employer
(The hire’s assignment location of employment)
Temporary Staffing Agency
Pay Frequency:_____________ Designated Pay Day:__________ Range of Potential Pay Rate:______-_______
(Weekly, bi-weekly, (Day of week when wages
semi-monthly, monthly, etc) are payable/available) Any Benefits:
Payday may vary depending upon the usual practice at the assignment
Tips $_____________ per hour
Meals $_____________ per meal
Lodging $_____________ per _______________
Other $_____________ per _______________
Legal entity responsible for Workers’ Compensation
should the employee be injured on the job:
_____________________________________________
Section 1
Section 2
Section 3
Anticipated length of the assignment: ___________-_____________
Training or Safety equipment required: Yes No
Who is obligated to provide and pay for equipment?
Assignment Particulars
Pay Frequency and Payday
Allowances Claimed As Part of Wages: □ None, or:
Palmer Staffing Services
1211 Connecticut Avenue NW
Suite 302
Wash., DC
20036
Weekly
Tuesday
x
Palmer Staffing Services
X
X
202 464 1000
Tipped Employees
As of January 1, 2005, the minimum wage required to be paid by any employer in the District of Columbia to any employee who receives gratuities
shall be $2.77 an hour, provided that the employee actually receives gratuities in an amount at least equal to the difference between the hourly
wage paid and the minimum wage. Also, all gratuities received by the employee must be retained by the employee. This employee (will or will not)
participate in the following company tip pool:
Tip Pool Policy: (Explain if applicable)
Section 4
Basis of Wage Payment
Pay Basis: _______________________ (hourly, shift, day, week, salary, piece, commission)
Rate of Pay: _________ per hour
Overtime Rate of Pay*_______ per hour
Overtime Pay Exemption for bona fide
Administrative
Executive
Professional
Hourly
Rate of Pay: _________ per ______________ Overtime Rate: _________
Rate of Pay: _________ per ______________ Overtime Rate: _________
Rate of Pay: _________ per ______________ Overtime Rate: _________
*No employer shall employ any employee for a workweek that is longer than
40 hours, unless the employee receives compensation for employment in
excess of 40 hours at a rate not less than 1 ½ times the regular rate at which
the employee is employed.
Multiple Rates or Basis (for each type of basis)
Minimum Wage Living Wage Living Wage Exempt Employer Determined Wage Rate
Prevailing Rate Jobs: Your rate of pay will be the posted rate for the classification(s) listed.
Classification 1: _______________________________________ Prevailing Rate: _____________________________
Classification 2: _______________________________________ Prevailing Rate: _____________________________
Classification 3: _______________________________________ Prevailing Rate: _____________________________
Prevailing Rate (if Applicable)
Section 7
Section 6
Section 5
Section 8
The Department of Employment Services, specifically the Office of Wage-Hour (OWH), is to be contacted as that office
is the designated enforcement agency for the concerns about safety, wage and hour, or discrimination. The OWH can
be contacted at 202-671-1880 or via e-mail at owh.ask@dc.gov. The office is located at 4058 Minnesota Avenue, NE,
Suite 4300 Washington, D.C. 20019. The office is open Monday Thursday 8:30-4:30 and Friday 9:30-4:30 .
Employee Acknowledgement: By signing below, I acknowledge that I have received the foregoing information regarding my pay
and my Employer. I told my employer what my primary language is:
Check one:
English
I have been given this pay notice in English.
Other Language
______________. I have been given this pay notice in English only, because Office of Wage-Hour does not yet offer a pay notice
form in my primary language.
Employee’s Signature: _____________________________________ Date____/____/_____
Employer’s Signature: _____________________________________ Date____/____/_____
X
Hourly
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
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
8. 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 Birth Abroad issued
by the Department of State (Form
FS-545)
3. Certification of Report of Birth
issued by the Department of State
(Form DS-1350)
4. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
5. Native American tribal document
7. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
6. 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 11/14/2016 N
Examples of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Form W-4
2020
Employee’s Withholding Certificate
Department of the Treasury
Internal Revenue Service
a
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
a
Give Form W-4 to your employer.
a
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
Step 1:
Enter
Personal
Information
(a) First name and middle initial Last name
Address
City or town, state, and ZIP code
(b) Social security number
a
Does your name match the
name on your social security
card? If not, to ensure you get
credit for your earnings, contact
SSA at 800-772-1213 or go to
www.ssa.gov.
(c)
Single or Married filing separately
Married filing jointly (or Qualifying widow(er))
Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can
claim exemption from withholding, when to use the 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 3–4); or
(b)
Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
(c)
If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option
is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld .....
a
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 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will
be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3:
Claim
Dependents
If your income will be $200,000 or less ($400,000 or less if married filing jointly):
Multiply the number of qualifying children under age 17 by $2,000
a
$
Multiply the number of other dependents
by $500 . . . .
a
$
Add the amounts above and enter the total here .............
3 $
Step 4
(optional):
Other
Adjustments
(a)
Other income (not from jobs). If you want tax withheld for other income you expect
this year that won’t have withholding, enter the amount of other income here. This may
include interest, dividends, and retirement income . . . . . . . . . . . .
4(a) $
(b)
Deductions. If you expect to claim deductions other than the standard deduction
and want to reduce your withholding, use the Deductions Worksheet on page 3 and
enter the result here .....................
4(b) $
(c) Extra withholding. Enter any additional tax you want withheld each pay period .
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.
F
Employee’s signature (This form is not valid unless you sign it.)
F
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)
Form W-4 (2020)
Page 2
General Instructions
Future Developments
For the latest information about developments related to
Form W-4, such as legislation enacted after it was published,
go to www.irs.gov/FormW4.
Purpose of Form
Complete Form W-4 so that your employer can withhold the
correct federal income tax from your pay. If too little is
withheld, you will generally owe tax when you file your tax
return and may owe a penalty. If too much is withheld, you will
generally be due a refund. Complete a new Form W-4 when
changes to your personal or financial situation would change
the entries on the form. For more information on withholding
and when you must furnish a new Form W-4, see Pub. 505.
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.
F
!
CAUTION
Multiple jobs. Complete Steps 3 through 4(b) on only
one Form W-4. Withholding will be most accurate if
you do this on the Form W-4 for the highest paying job.
Step 3. 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.
Form W-4 (2020)
Page 3
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)
If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE
Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.
Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional
tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
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 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
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 $
2 Enter:
{
• $24,800 if you’re married filing jointly or qualifying widow(er)
• $18,650 if you’re head of household
• $12,400 if you’re single or married filing separately
}
........ 2 $
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.
Form W-4 (2020)
Page 4
Married Filing Jointly or Qualifying Widow(er)
Higher Paying Job
Annual Taxable
Wage & Salary
Lower Paying Job Annual Taxable Wage & Salary
$0 -
9,999
$10,000 -
19,999
$20,000 -
29,999
$30,000 -
39,999
$40,000 -
49,999
$50,000 -
59,999
$60,000 -
69,999
$70,000 -
79,999
$80,000 -
89,999
$90,000 -
99,999
$100,000 -
109,999
$110,000 -
120,000
$0 - 9,999 $0 $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
click to sign
signature
click to edit
click to sign
signature
click to edit
Government of the
District of Columbia
Employer Keep this certificate with your records. If 10 or more exemptions are claimed or if you suspect this certificate contains false information
please send a copy to: Office of Tax and Revenue, 1101 4th St., SW, Washington, DC 20024 Attn: Compliance Administration
Signature Under penalties of law, I declare that the information provided on this certifi cate is, to the best of my knowledge, correct.
Employee’s signature Date
D-4 DC Withholding Allowance Worksheet
Government of the
District of Columbia
Section A Number of withholding allowances
a Enter 1 for yourself
a
c Enter 1 if you are 65 or over c
d Enter 1 if you are blind d
e
e Enter number of dependents
f Enter 1 for your spouse or registered domestic partner filing jointly or filing separately on same return or if you are a qualifying widow(er)
with dependent child
f
g Enter 1 if married or registered domestic partner filing jointly or filing separately on same return and your spouse or registered domestic
partner is 65 or over
g
h
h Enter 1 if married or registered domestic partner filing jointly or filing separately on same return and your spouse or registered domestic
partner is blind
i Number of allowances Add Lines a through h, enter here and on Line 2 above, next to "Enter total from Sec. A, Line i".
If you want to claim additional withholding allowances, complete Section B below.
i
Revised 10/2017
Taxpayer identification number (TIN) See instructions.
First name
M.I. Last name
Home address (number, street and suite/apartment number if applicable)
City State Zip code +4
Single
Married/domestic partners fi ling jointly/qualifying widow(er) with dependent child
Married fi ling separately
Head of household
Married/domestic partners fi ling separately on same return
2 Total number of withholding allowances from worksheet below.
Enter total from Sec. A, Line i Enter total from Sec. B, Line m
Total number of withholding allowances , Line n
3 Additional amount, if any, you want withheld from each paycheck
4 Before claiming exemption from withholding, read below. If quali ed, write “EXEMPT in this box.
5 My domicile is a state other than the District of Columbia Yes No If yes, give name of state of domicile __________________
I am exempt because: last year I did not owe any DC income tax and had a right to a full refund of all DC income tax withheld from me; and this year I do
not expect to owe any DC income tax and expect a full refund of all DC income tax withheld from me; and I qualify for exempt status on federal Form W-4.
If claiming exemption from withholding, are you a full-time student?
Yes No
D-4 DC Withholding Allowance Certificate
Detach and give the top portion to your employer. Keep the bottom portion for your records.
$
Section B Additional withholding allowances
jj Enter estimate of your itemized deductions
k Enter $6,500 if single, married/registered domestic partners filing separately or a dependent. Enter $9,550 if
n
1 Tax fi ling status (Fill in only one)
2018
m
Add Lines m and i, enter here and on Line 2 above, next to "Total number of withholding allowances, Line n".
l
m
n
b Enter 1 if you are filing as a head of household
b
head of household. Enter $13,000 if married/registered domestic partner ling join
tly, married
filing separately on the same return, or qualifying widow(er) with dependent child.
k
Subtract Line k from Line j
l
Divide Line l by $4,150. Round to the nearest whole number, enter here and on Line 2 above, next to "Enter total from Sec.B, Line m".
Under the penalty of perjury, I further certify that I am entitled to the number of withholding allowances claimed on line 1 above, or if claiming exemption
from withholding, that I am entitled to claim the exempt status on whichever line(s) I completed.
Employee’s signature Date
Employer’s name and address including ZIP code (For employer use only) Federal Employer Identication Number
1. Total number of exemptions you are claiming not to exceed line f in Personal Exemption Worksheet on page 2. ...................... 1. ______________
2. Additional withholding per pay period under agreement with employer. .................................................... 2. ______________
3. I claim exemption from withholding because I do not expect to owe Maryland tax. See instructions above and check boxes that apply.
a. Last year I did not owe any Maryland income tax and had a right to a full refund of all income tax withheld and
b. This year I do not expect to owe any Maryland income tax and expect to have the right to a full refund of all income tax withheld.
(This includes seasonal and student employees whose annual income will be below the minimum ling requirements).
If both a and b apply, enter year applicable _____________ (year effective) Enter “EXEMPT” here ......................... 3. ______________
4. I claim exemption from withholding because I am domiciled in one of the following states. Check state that applies.
District of Columbia Virginia West Virginia
I further certify that I do not maintain a place of abode in Maryland as described in the instructions above. Enter “EXEMPT” here. ......... 4. ______________
5. I claim exemption from Maryland state withholding because I am domiciled in the Commonwealth of Pennsylvania and I do not
maintain a place of abode in Maryland as described in the instructions on Form MW507. Enter “EXEMPT” here.
....................... 5. ______________
6. I claim exemption from Maryland local tax because I live in a local Pennysylvania jurisdiction within York or Adams counties.
Enter “EXEMPT” here and on line 4 of Form MW507.
.................................................................. 6. ______________
7. I claim exemption from Maryland local tax because I live in a local Pennsylvania jurisdiction that does not impose an earnings or income
tax on Maryland residents. Enter “EXEMPT” here and on line 4 of Form MW507.
............................................. 7. ______________
8. I certify that I am a legal resident of the state of ____________ and am not subject to Maryland withholding because l meet the require-
ments set forth under the Servicemembers Civil Relief Act, as amended by the Military Spouses Residency Relief Act. Enter “EXEMPT” here.
... 8. ______________
COM/RAD-036 17-49
MARYLAND
FORM
MW507
Employee’s Maryland Withholding Exemption Certicate
FORM
MW507
Print full name Social Security Number
Street Address, City, State, ZIP
County of residence (Nonresidents enter Maryland county (or Baltimore City) where you are employed.)
Single Married (surviving spouse or unmarried Head of Household) Rate Married, but withhold at Single rate
Purpose. Complete Form MW507 so that your employer can withhold the correct
Maryland income tax from your pay. Consider completing a new Form MW507
each year and when your personal or nancial situation changes.
Basic Instructions. Enter on line 1 below, the number of personal exemptions
you will claim on your tax return. However, if you wish to claim more exemptions,
or if your adjusted gross income will be more than $100,000 if you are ling
single or married ling separately ($150,000, if you are ling jointly or as head
of household), you must complete the Personal Exemption Worksheet on page
2. Complete the Personal Exemption Worksheet on page 2 to further adjust your
Maryland withholding based on itemized deductions, and certain other expenses
that exceed your standard deduction and are not being claimed at another job or
by your spouse. However, you may claim fewer (or zero) exemptions.
Additional withholding per pay period under agreement with employer. If
you are not having enough tax withheld, you may ask your employer to withhold
more by entering an additional amount on line 2.
Exemption from withholding. You may be entitled to claim an exemption from
the withholding of Maryland income tax if:
a. Last year you did not owe any Maryland Income tax and had a right to a full
refund of any tax withheld; AND,
b. This year you do not expect to owe any Maryland income tax and expect to have
a right to a full refund of all income tax withheld.
If you are eligible to claim this exemption, complete Line 3 and your employer will
not withhold Maryland income tax from your wages.
Students and Seasonal Employees whose annual income will be below the mini
-
mum ling requirements should claim exemption from withholding. This provides
more income throughout the
year and avoids the necessity of ling a Maryland
income tax return.
Certication of nonresidence in the State of Maryland. Complete Line 4. This
line is to be completed by residents of the District of Columbia, Virginia or West
Virginia who are employed in Maryland and who do not maintain a place of abode
in Maryland for 183 days or more.
Residents of Pennsylvania who are employed in Maryland and who do not maintain
a place of abode in Maryland for 183 days or more, should complete line 5 to ex
-
empt themselves from the state portion of the withholding tax. These employees
are still liable for withholding tax at the rate in effect for the Maryland county in
which they
are employed, unless they qualify for an exemption on either line 6 or
line 7. Pennsylvania residents of York and Adams counties may claim an exemp-
tion from the local withholding tax by completing line 6. Pennsylvania residents
living in other local jurisdictions which do not impose an earnings or income tax
on Maryland residents may claim an exemption by completing line 7. Employees
qualifying for exemption under 6 or 7, should also write “EXEMPT” on line 4.
Line 4 is NOT to be used by residents of other states who are working in Maryland,
because such persons are liable for Maryland income tax and withholding from
their wages is required.
If you are domiciled in the District of Columbia, Pennsylvania or Virginia and main
-
tain a place of abode in Maryland for 183 days or more, you become a statutory
resident of Maryland and you are required to le a resident return with Maryland
reporting your total income. You must apply to your domicile state for any tax
credit to which you may be entitled under the reciprocal provisions of the law. If
you are domiciled in West Virginia, you are not required to pay Maryland income
tax on wage or salary income, regardless of the length of time you may have
spent in Maryland.
Under the Servicemembers Civil Relief Act, as amended by the Military Spouses
Residency Relief Act, you may be exempt from Maryland income tax on your
wages if (i) your spouse is a member of the armed forces present in Maryland in
compliance with military orders; (ii) you are present in Maryland solely to be with
your spouse; and (iii) you maintain your domicile in another state. If you claim
exemption under the SCRA enter your state of domicile (legal residence) on Line
8; enter “EXEMPT” in the box to the right on Line 8; and attach a copy of your
spousal military identication card to Form MW507. In addition, you must also
complete and attach Form MW507M.
Duties and responsibilities of employer. Retain this certicate with your re
-
cords. You are required to submit a copy of this certicate and accompanying
attachments to the
Compliance Division, Compliance Programs Section, 301 West
Preston Street, Baltimore, MD 21201, when received if:
1. You have any reason to believe this certicate is incorrect;
2. The employee claims more than 10 exemptions;
3. The employee claims an exemption from withholding because he/she had no
tax liability for the preceding tax year, expects to incur no tax liability this year
and the wages are expected to exceed $200 a week;
4. The employee claims an exemption from withholding on the basis of nonresi
-
dence; or
5.
The employee claims an exemption from withholding under the Military Spous-
es Residency Relief Act.
Upon receipt of any
exemption certicate (Form MW507), the Compliance Division
will make a determination and notify you if a change is required.
Once a certicate is revoked by the Comptroller, the employer must send any new
certicate from the employee to the Comptroller for approval before implementing
the new certicate.
If an employee claims exemption under 3 above, a new exemption certicate must
be led by February 15th of the following year.
Duties and responsibilities of employee. If, on any day during the calendar
year, the number of withholding exemptions that the employee is entitled to claim
is less than the number of exemptions claimed on the withholding exemption cer
-
ticate in effect, the employee must le a new withholding exemption certicate
with the employer within 10 days af
ter the change occurs.
COMMONWEALTH OF VIRGINIA
DEPARTMENT OF TAXATION
PERSONAL EXEMPTION WORKSHEET
(See back for instructions)
1. If you wish to claim yourself, write “1” .............................................................. _______________
2. If you are married and your spouse is not claimed
onhisorherowncerticate,write“1” ............................................................... _______________
3. Write the number of dependents you will be allowed to claim
on your income tax return (do not include your spouse) ................................... _______________
4. Subtotal Personal Exemptions (add lines 1 through 3) ..................................... _______________
5. Exemptions for age
(a) If you will be 65 or older on January 1, write “1” .................................. _______________
(b) If you claimed an exemption on line 2 and your spouse
will be 65 or older on January 1, write “1” ............................................ _______________
6. Exemptions for blindness
(a) If you are legally blind, write “1” ........................................................... _______________
(b) If you claimed an exemption on line 2 and your
spouse is legally blind, write “1” ........................................................... _______________
7. Subtotal exemptions for age and blindness (add lines 5 through 6) ................................................... ______________
8. Total of Exemptions - add line 4 and line 7 ......................................................................................... ______________
Detach here and give the certicate to your employer. Keep the top portion for your records
FORM VA-4 EMPLOYEE’S VIRGINIA INCOME TAX WITHHOLDING EXEMPTION CERTIFICATE
COMPLETE THE APPLICABLE LINES BELOW
1. If subject to withholding, enter the number of exemptions claimed on:
(a) Subtotal of Personal Exemptions - line 4 of the
Personal Exemption Worksheet ...........................................................................................
(b) Subtotal of Exemptions for Age and Blindness
line 7 of the Personal Exemption Worksheet .......................................................................
(c) Total Exemptions - line 8 of the Personal Exemption Worksheet.........................................
2. Enter the amount of additional withholding requested (see instructions) .......................................... .
3. I certify that I am not subject to Virginia withholding. l meet the conditions
set forth in the instructions ................................................................................. (check here)
4. I certify that I am not subject to Virginia withholding. l meet the conditions set forth
Under the Service member Civil Relief Act, as amended by the Military Spouses
Residency Relief Act .......................................................................................... (check here)
Signature Date
EMPLOYER:Keepexemptioncerticateswithyourrecords.Ifyoubelievetheemployeehasclaimedtoomanyexemptions,notifytheDepartmentof
Taxation, P.O. Box 1115, Richmond, Virginia 23218-1115, telephone (804) 367-8037. Note: Employers may establish a system to electronically receive
FormsVA-4fromemployees,providedthesystemmeetsInternalRevenueServicerequirementsasspeciedin§31.3402(f)(5)-1(c)oftheTreasury
Regulations (26 CFR).
FORM VA-4
Your Social Security Number Name
Street Address
City State Zip Code
2601064 Rev. 08/11
s
He
re is an example of how you can save money:
Employee’s Annual Pre-Tax Salary Deduction for Transit
$3,060
Federal Income Tax Saved (25%)
($765)
Employee FICA Saved (7.65%)
($234.09)
State Income Tax Saved (6%)
($183.60)
Total Annual Cost to Employee
$1,877.31
Total Annual Savings to Employee
($1,182.69)
Assumptions: Employee pays 25% in federal income tax; employee pays 6% in state income tax
BENEFITS SHEET
Holiday Pay
Palmer Staffing Services observes 6 holidays (New Year’s Day, Memorial Day, 4
th
of July, Labor Day,
Thanksgiving, Christmas). Candidates are eligible for holiday pay once they have worked 1,000 hours or
more within a one-year period from the holiday date and work the full week before and after the holiday.
Paid-Time Off (PTO)
Paid-Time Off (PTO) provides payment to employees for scheduled and unscheduled time off from work,
including vacation, personal business, appointments, personal illness, and time off for family members and
for other domestic situations. PTO generally must be scheduled in advance and have supervisory approval,
except in the case of illness or emergency. PTO is in addition to time off which Palmer may make available
to employees for holidays, military leave, or jury duty leave. Candidates are eligible for PTO after they have
worked 1,500 hours within a one-year period. PTO equals 35 hours. You will be paid the average hourly
rate worked during the 1,500 hours.
Accrued Sick and Safe Leave
Employees who are not yet eligible for PTO may be eligible for paid leave to cover absences related to their
own or a family member’s illness or absences related to stalking or domestic violence pursuant to the D.C.
Accrued Sick and Safe Leave Act of 2008 (“ASSLA”). Employees begin accruing leave on their date of hire
(one hour of paid leave for every 43 hours worked, not to exceed 5 days per year) and can start using
accrued leave as soon as they have worked at Palmer for 90 days. Unused paid leave will carry over
annually, but an employee can only use a maximum of 5 days per year. Any sick leave used by an eligible
employee pursuant to ASSLA will be counted towards the 35 hours of PTO, and employees will not be
compensated for unused sick leave at the end of employment.
Palmer may require that an employee who is out on leave for 3 consecutive days provide a medical
certification, police report, court order, or signed victim or witness statement supporting the reason for leave.
If leave is foreseeable, employees must make a written request at least 10 days in advance of the leave,
including the reason for the absence and the expected duration of the leave. If the leave is unforeseeable,
an oral request for paid leave must be made prior to the start of the work shift for which paid leave is
requested. In the case of emergency, employees must notify Palmer prior to the start of the next work shift
or within 24 hours of the onset of the emergency, whichever occurs sooner.
Direct Deposit All candidates are encouraged to utilize direct deposit.
DC Commuter Benefit Ordinance
If you get to work by bus, Metro, commuter rail or vanpool, you can elect to withhold up to $270 per month
from your pay, tax-free, toward commuting costs. Full-time and part-time employees are eligible to enroll.
You must have a registered Metro SmarTrip® card. Signing up is easy just ask us for an enrollment form!
GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF EMPLOYMENT SERVICES
NOTICE TO EMPLOYEES
New Benefit Available Beginning in July 2020
Information on Paid Family Leave in the District of Columbia
Your employer is subject to the District of Columbia’s Paid Family Leave law, which allows covered employees to receive
paid time off for qualifying parental, family, and medical events. For more information about Paid Family Leave, please
visit the Office of Paid Family Leave’s website at dcpaidfamilyleave.dc.gov.
Covered Workers
In order to receive benefits under the Paid Family Leave
program, you must have worked for an employer in DC
before you experienced a covered event. Your employer
should have reported your wages to the Department of
Employment Services and paid taxes based on the
wages they paid to you. To find out if you are a
covered worker, you can ask your employer or contact
the Office of Paid Family Leave using the information
below. Your employer is required to tell you if you are
covered by the Paid Family Leave program. You
should receive information about Paid Family Leave
from your employer at these three (3) times:
1. At the time you were hired (if you were hired after
January 2020);
2. At least once a year starting in 2020; and
3. If (in 2020 or later) you ever asked your employer for
leave that could qualify for benefits under the Paid
Family Leave program.
Covered Events
There are three (3) kinds of events for which you may be
eligible for Paid Family Leave benefits. Each kind of leave
has its own eligibility rules and its own limit on the length
of time you can receive benefits in a year. No matter
how many different types of leave you may take in a
year, you may receive no more than 8 weeks of Paid
Family Leave benefits in a year. The three types of leave
for which you may receive benefits are:
1. Parental leave - receive benefits to bond with a new
child for up to 8 weeks in a year;
2. Family leave - receive benefits to care for a family
member for up to 6 weeks in a year; and
3. Medical leave - receive benefits for your own serious
health condition for up to 2 weeks in a year.
Applying for Benefits
If you have experienced an event that may qualify for
parental, family, or medical leave benefits, you can learn
more about applying for benefits with the Office of Paid
Family Leave at dcpaidfamilyleave.dc.gov.
Benefit Amounts
Paid Family Leave benefits are based on the wages your
employer paid to you and reported to the Department
of Employment Services. If you believe your wages
were reported incorrectly, you have the right to
provide proof of your correct wages. Effective July 1,
2020 through October 1, 2021, the maximum weekly
benefit amount is $1,000.
Employee Protection
The Paid Family Leave program does not provide job
protection to you when you take leave and receive Paid
Family Leave benefits. However, you may be protected
against actions taken by your employer that are harmful
to you if those actions were taken because you applied
for or claimed Paid Family Leave benefits. When these
harmful actions were taken because you applied for or
claimed Paid Family Leave benefits, they are known as
“retaliation. If you believe you have been retaliated
against, you may file a complaint with the DC Office of
Human Rights (OHR), which receives complaints at the
following web address: www.ohr.dc.gov.
For more information about Paid Family Leave, please visit the Office of Paid Family Leave’s website at dcpaidfamilyleave.dc.gov, call
202-899-3700, or email does.opfl@dc.gov.
Office of Paid Family Leave | 4058 Minnesota Avenue NE | Washington DC 20019
OPFL EE Rev. 12/2019
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