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Verifying the candidate's employment with a Professional Reference (City of Waterbury, CT)

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Pre-Employment Questionnaire
Do Not Complete: For Office Use Only:
Email @
Tel. #:
(
)
-
Ext
to
Candidate Name:
Please select that which best describes you:
Verifying the candidate's employment with a Professional Reference for the candidate
company/organization
Your Name:
Your Title/Relationship with Candidate:
With what Company/Organization were you both involved?
Dates candidate was with your company/organization
Knowledge Skills Abilities
Circle one: 1 = Needs Improvement 2 = Satisfactory 3 = Exceeds Expectations
Comments
Job Knowledge
1
2
3
Quantity of Work
1
2
3
Quality of Work
1
2
3
Customer Service
1
2
3
Compliance with Policies & Procedures
1
2
3
Reliability (Attendance & Timeliness)
1
2
3
Relationships with Supervisors/Peers/Customers
1
2
3
Communication (Written)
1
2
3
Communication (Oral)
1
2
3
Work Ethic/Drive to get Results
1
2
3
Judgement/Decision Making Ability
1
2
3
Time Management/Setting Priorities
1
2
3
Supervisory Ability (if applicable)
1
2
3
SIGNATURE: DATE:
The City of Waterbury
236 Grand Street
Waterbury, CT 06702
(203) 574-6761
Connecticut
Department of Human Resources
Office of the Civil Service Commission
Please describe the candidate's duties (or how the candidate added value to your organization):
Please describe an area of strength for the candidate:
Please describe an area of development for future training:
Would your company or organization have the candidate back (or rehire)? If not, why not?
Did the candidate ever engage in misconduct of any kind? If yes, please explain.
Pre-Employment Questionnaire
Do Not Complete: For Office Use Only:
Email @
Tel. #:
(
)
-
Ext
TO BE COMPLETED BY APPLICANT
I voluntarily give the Civil Service Commission of the City of Waterbury, Connecticut, or its duly authorized representative
the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation, and
release from all liability or responsibility all persons, companies, or corporations supplying such information.
Applicant Name (Print)
Signature
Date -
CRIMINAL CONVICTIONS:
Answers to the following question will be considered for employment purposes if relevant to the position for which you are
applying. Have you ever been CONVICTED of an offense against criminal or military law, or are there criminal charges currently
pending against you? (Exclude minor traffic violations or any offense settled in juvenile court or under a youth offender law.)
Yes No
If, ‘YES”, below please provide a detailed explanation about the nature of the conviction, degree of rehabilitation and time since
release. This information will not necessarily bar you from employment.
Special Note: You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which
have been erased pursuant to Connecticut General Statutes § 46b-146, 54-760, or 54-142a. If your criminal records have been
erased pursuant to one of these statutes, you may swear under oath that you have never been arrested. Criminal records that
may be erased are records pertaining to a finding of delinquency or that a child was a member of a family with service needs
(C.G.S. § 46b-146), an adjudication as a youthful offender (C.G.S § 54-760), a criminal charge that has been dismissed or knolled,
a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute
pardon (C.G.S. § 54-1421a).
DISMISSAL:
Have you ever been dismissed from employment for inefficiency, delinquency or misconduct?) Yes No
If, “Yes”, below please provide a detailed explanation.
CERTIFICATION:
I certify that the statements made by me on this release form are true and complete to the best of my knowledge and are made
in good faith. I understand that if I knowingly make any misstatement of fact, I am subject to disqualification and dismissal and
to such other penalties as may be prescribed by law or personnel regulations.
Signature ___________________________________________ Date _________________________________
Name _____________________________________
Professional references/Verifications
Please provide the name, email address, telephone number, & nature of relationship for each
reference. Please confirm ALL emails and numbers are correct before submitting them.
References should be:
Individuals who have seen your work, volunteer, sports, or academic efforts firsthand
(Teachers, Coaches, Volunteer Directors, Supervisors, or Co-workers)
Aware that we will be contacting them and be willing to participate
Able to comment on your work habits (work ethic, attendance, etc.)
Able to respond within one (1) business day of request
References should NOT be:
Casual Acquaintances, Friends or neighbors who can only tell us that you’re a “good kid.”
Family members
Too busy to promptly respond
REF 1
Name
Email
Tel #
How Do They Know You?
REF 2
Name
Email
Tel #
How Do They Know You?
REF 3
Name
Email
Tel #
How Do They Know You?
ALTERNATE REF (in case one listed above does not reply)
Name
Email
Tel #
How Do They Know You?
**Use back of page for Employment Verification (if needed) **
www.sterlinginfosystems.com Page 1 of 5
1 State Street 24
th
Floor, New York, NY 10004 Telephone 877-424-2457 Facsimile 646-536-5239
07/2013
Consent to Request Consumer Report & Investigative Consumer Report Information
Applicant's First Name or Initial Last Name
I understand that CITY OF WATERBURY (“COMPANY”) will use Sterling Infosystems Inc., 1 State Street, New York, NY 10004,
(877) 424-2457 to obtain a consumer report and/or investigative consumer report (“Report”) for employment purposes. I also
understand that if hired, to the extent permitted by law, COMPANY may obtain further Reports throughout my employment for an
employment purpose from Sterling.
I understand Sterling Infosystems Inc.’s (“STERLING”) investigation may include obtaining information regarding my credit
background, bankruptcies, lawsuits, judgments, paid tax liens, unlawful detainer actions, failure to pay spousal or child support,
accounts placed for collection, character, general reputation, personal characteristics and standard of living, driving record and criminal
record, subject to any limitations imposed by applicable federal and state law. I understand such information may be obtained
through direct or indirect contact with former employers, schools, financial institutions, landlords and public agencies or other persons
who may have such knowledge. If an investigative consumer report is being requested, I understand such information may be
obtained through any means, including but not limited to personal interviews with my acquaintances and/or associates or with others
whom I am acquainted.
The nature and scope of the investigation sought is indicated by the selected services below: (Employer Use Only)
Criminal Background Check
Education Verification
Sex Offender Search
SSN Trace/Address Locator
Employment Verification
OFAC/Terrorist Watch List
Motor Vehicle Report
Personal Reference Verification
Fraud & Abuse Control Info System (FACIS®)
Employment Credit Report
Professional License/Certification
Office of Inspector General Sanctions (OIG)
Other Please List:
I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related
state summary of rights (collectively “Summaries of Rights”).
This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if
COMPANY makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report
and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying information in the
Report, I must notify COMPANY within five business days of my receipt of the Report that I am challenging the accuracy of such
information with STERLING.
I hereby consent to this investigation and authorize COMPANY to procure a Report on my background.
In order to verify my identity for the purposes of Report preparation, I am voluntarily releasing my date of birth, social security
number and the other information and fully understand that all employment decisions are based on legitimate non-discriminatory
reasons.
The name, address and telephone number of the nearest unit of the consumer reporting agency designated to handle inquiries
regarding the investigative consumer report is:
Sterling Infosystems, Inc. | 1 State Street, 24
th
Floor, New York, NY 10004 | 877-424-2457 | or | 5750 West Oaks Boulevard, Ste. 100
Rocklin, CA 95765 | 800-943-2589 |or | 6111 Oak Tree Boulevard, Independence, OH 44131 |800-853-3228
California, Maine, Massachusetts, Minnesota, New Jersey & Oklahoma Applicants Only: I have the right to request a copy
of any Report obtained by COMPANY from STERLING by checking the box. (Check only if you wish to receive a copy)
California, Colorado, Connecticut, Maryland, Oregon, Vermont and Washington State Applicants Only (AS APPLICABLE):
I further understand that COMPANY will not obtain information about my credit history, credit worthiness, credit standing, or credit
capacity unless: (i) the information is required by law; (ii) I am seeking employment with a financial institution (California,
Colorado, Connecticut and Vermont only – in California the financial institution must be subject to Sections 6801-6809 of the U.S.
Code and in Vermont it must be a financial institution as defined in 8 V.S.A.§ 11101(32) or a credit union as defined in 8 V.S.A. §
30101(5)); (iii) I am seeking employment with a financial institution that accepts deposits that are insured by a federal agency, or an
affiliate or subsidiary of the financial institution or a credit union share guaranty corporation that is approved by the Maryland
Commissioner of Financial Regulation or an entity or an affiliate of the entity that is registered as an investment advisor with the
United States Securities and Exchange Commission (Maryland only); (iv) I am seeking employment in a position which involves
www.sterlinginfosystems.com Page 2 of 5
1 State Street 24
th
Floor, New York, NY 10004 Telephone 877-424-2457 Facsimile 646-536-5239
07/2013
access to confidential financial information (Vermont only); (v) I am seeking employment in a position which requires a financial
fiduciary responsibility to the employer or a client of the employer, including the authority to issue payments, collect debts,
transfer money, or enter into contracts (Vermont only); (vi) COMPANY can demonstrate that the information is a valid and reliable
predictor of employee performance in the specific position being sought or held; (vii) I am seeking employment in a position that
involves access to an employer’s payroll information (Vermont only); (viii) the information is substantially job related, and the
bona fide reasons for using the information are disclosed to me in writing, (complete the question below) (Colorado,
Connecticut, Maryland, Oregon and Washington only);(ix) I am seeking employment as a covered law enforcement officer,
emergency medical personnel, firefighter police officer, peace officer or other law enforcement position (California, Oregon and
Vermont only - in Oregon the police or peace officer position must be sought with a federally insured bank or credit union and in
Vermont the law enforcement officer position must be as defined in 20 V.S.A. § 2358, the emergency medical personnel must be
as defined in 24 V.S.A. § 2651(6), and the firefighter position must be as defined in 20 V.S.A. § 3151(3)); (x) the COMPANY
reasonably believes I have engaged in specific activity that constitutes a violation of law related to my employment (Connecticut
only); (xi) I am seeking a position with the state Department of Justice (California only); (xii) I am seeking a position as an exempt
managerial employee (California only); and/or (xiii)) I am seeking employment in a position (other than regular solicitation of credit
card applications at a retail establishment) that involves regular access to all of the following personal information of any one person:
bank or credit card account information, social security number, and date of birth,, I am seeking employment in a position that
requires me to be a named signatory on the employer’s bank or credit card or otherwise authorized to enter into financial contracts
on behalf of the employer, I am seeking employment in a position that involves access to confidential or proprietary information of
the Company or regular access to $10,000 or more in cash (California only).
Bona fide reasons why COMPANY considers credit information substantially job related (complete if this is the sole
basis for obtaining credit information) or in California and Vermont the COMPANY’S basis for the credit check.
___________________________________________________________________________________________________________
NY Applicants Only: I also acknowledge that I have received the attached copy of Article 23A of New York’s Correction Law. I further
understand that I may request a copy of any investigative consumer report by contacting STERLING. I further understand that I will be
advised if any further checks are requested and provided the name and address of the consumer reporting agency.
California Applicants and Residents: If I am applying for employment in California or reside in California, I understand I have the
right to visually inspect the files concerning me maintained by an investigative consumer reporting agency during normal business
hours and upon reasonable notice. The inspection can be done in person, and, if I appear in person and furnish proper identification; I
am entitled to a copy of the file for a fee not to exceed the actual costs of duplication. I am entitled to be accompanied by one person
of my choosing, who shall furnish reasonable identification. The inspection can also be done via certified mail if I make a written
request, with proper identification, for copies to be sent to a specified addressee. I can also request a summary of the information to
be provided by telephone if I make a written request, with proper identification for telephone disclosure, and the toll charge, if any, for
the telephone call is prepaid by or directly charged to me. I further understand that the investigative consumer reporting agency shall
provide trained personnel to explain to me any of the information furnished to me; I shall receive from the investigative consumer
reporting agency a written explanation of any coded information contained in files maintained on me. “Proper identification” as used
in this paragraph means information generally deemed sufficient to identify a person, including documents such as a valid driver’s
license, social security account number, military identification card and credit cards. I understand that I can access the following
website http://sterlinginfosystems.com/privacy to view STERLING’S privacy practices, including information with respect to
STERLING’S preparation and processing of investigative consumer reports and guidance as to whether my personal information will be
sent outside the United States or its territories.
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a
written summary of your rights and remedies under the Washington Fair Credit Reporting Act.
_______________________________________________________________________________ _______________
Signature: Today’s Date:
www.sterlinginfosystems.com Page 3 of 5
1 State Street 24
th
Floor, New York, NY 10004 Telephone 877-424-2457 Facsimile 646-536-5239
07/2013
For Office Use Only – Group ID (optional)
For Office Use Only – User ID (optional)
For Office Use Only – Location / Store # (optional)
First Name Middle Name or Initial
Last Name Date of Birth (MMDDYYYY)
Other Names Known By Male Female
Social Security Number Primary Telephone Number (no dashes)
Current Address Apt # #yrs at this address
City State Zip Code
Previous Address Apt # #yrs at this address
City State Zip Code
Driver’s License Number (no dashes) License State
Email Address
Signature Today’s Date (MMDDYYYY) ARMEN
www.sterlinginfosystems.com Page 4 of 5
1 State Street 24
th
Floor, New York, NY 10004 Telephone 877-424-2457 Facsimile 646-536-5239
07/2013
Para información en español, visite www.consumerfinance.gov/learnmore o escribe a la Consumer Financial Protection Bureau,
1700 G Street N.W., Washington, DC 20552.
A Summary of Your Rights Under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer
reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as
agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your
major rights under the FCRA. For more information, including information about additional rights, go to
www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC
20552.
• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of
consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell
you, and must give you the name, address, and phone number of the agency that provided the information.
• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer
reporting agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security
number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:
• a person has taken adverse action against you because of information in your credit report;
• you are the victim of identify theft and place a fraud alert in your file;
• your file contains inaccurate information as a result of fraud;
• you are on public assistance;
• you are unemployed but expect to apply for employment within 60 days.
In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from
nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.
• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information
from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in
residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information
for free from the mortgage lender.
• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or
inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See
www.consumerfinance.gov/learnmore for an explanation of dispute procedures.
• Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete
or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue
to report information it has verified as accurate.
• Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not
report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.
• Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need –
usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid
need for access.
• You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information
about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is
not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.
• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited
“prescreened” offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and
address from the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1-888-567-8688.
• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher
of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.
www.sterlinginfosystems.com Page 5 of 5
1 State Street 24
th
Floor, New York, NY 10004 Telephone 877-424-2457 Facsimile 646-536-5239
07/2013
• Identity theft victims and active duty military personnel have additional rights. For more information, visit
www.consumerfinance.gov/learnmore
States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more
rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney
General. For information about your federal rights, contact:
TYPE OF BUSINESS: CONTACT:
1.a. Banks, savings associations, and credit unions with total assets of
over $10 billion and their affiliates.
a. Consumer Financial Protection Bureau
1700 G Street NW Washington, DC 20552
b. Such affiliates that are not banks, savings associations, or credit
unions also should list, in addition to the CFPB:
b. Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580
(877) 382-4357
2. To the extent not included in item 1 above:
a. National banks, federal savings associations, and federal branches
and federal agencies of foreign banks
a. Office of the Comptroller of the Currency
Customer Assistance Group
1301 McKinney Street, Suite 3450
Houston, TX 77010-9050
b. State member banks, branches and agencies of foreign banks (other
than federal branches, federal agencies, and Insured State Branches
of Foreign Banks), commercial lending companies owned or controlled
by foreign banks, and organizations operating under section 25 or 25A
of the Federal Reserve Act
b. Federal Reserve Consumer Help Center
P.O. Box 1200 Minneapolis, MN 55480
c. Nonmember Insured Banks, Insured State Branches of Foreign
Banks, and insured state savings associations
c. FDIC Consumer Response Center
1100 Walnut Street, Box #11
Kansas City, MO 64106
d. Federal Credit Unions
d. National Credit Union Administration
Office of Consumer Protection (OCP)
Division of Consumer Compliance and Outreach (DCCO)
1775 Duke Street
Alexandria, VA 22314
3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings
Aviation Consumer Protection Division Department of Transportation
1200 New Jersey Avenue, SE Washington, DC 20590
4. Creditors Subject to Surface Transportation Board Office of Proceedings, Surface Transportation Board
Department of Transportation 395 E Street S.W. Washington, DC
20423
5. Creditors Subject to Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor
6. Small Business Investment Companies Associate Deputy Administrator for Capital Access
United States Small Business Administration 409 Third Street, SW, 8th
Floor Washington, DC 20416
7. Brokers and Dealers Securities and Exchange Commission 100 F St NE Washington, DC
20549
8. Federal Land Banks, Federal Land Bank Associations, Federal
Intermediate Credit Banks, and Production Credit Associations
Farm Credit Administration 1501 Farm Credit Drive McLean, VA
22102-5090
Farm Credit Administration 1501 Farm Credit Drive McLean, VA
22102-5090
9. Retailers, Finance Companies, and All Other Creditors Not Listed
Above
FTC Regional Office for region in which the creditor operates or
Federal Trade Commission: Consumer Response Center – FCRA
Washington, DC 20580 (877) 382-4357
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Form I-9 10/21/2019
Page 1 of 3
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,
during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an
employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the
documentation presented has a future expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
ZIP Code
Date of Birth (mm/dd/yyyy)
-
-
Employee's E-mail Address
Employee's Telephone Number
U.S. Social Security Number
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident
4. An alien authorized to work until
(See instructions)
(expiration date, if applicable, mm/dd/yyyy):
(Alien Registration Number/USCIS Number):
Some aliens may write "N/A" in the expiration date field.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in
connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
1. Alien Registration Number/USCIS Number:
2. Form I-94 Admission Number:
3. Foreign Passport Number:
Country of Issuance:
OR
OR
QR Code - Section 1
Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my
knowledge the information is true and correct.
Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
ZIP Code
Employer Completes Next Page
Form I-9 10/21/2019
Page 2 of 3
USCIS
Form I-9
OMB No. 1615-0047
Expires 10/31/2022
Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You
must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists
of Acceptable Documents.")
Last Name (Family Name) M.I.
First Name (Given Name)
Employee Info from Section 1
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Identity
Employment Authorization
OR List B AND List C
Additional Information
QR Code - Sections 2 & 3
Do Not Write In This Space
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,
(2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the
employee is authorized to work in the United States.
The employee's first day of employment (mm/dd/yyyy):
(See instructions for exemptions)
Today's Date (mm/dd/yyyy)
Signature of Employer or Authorized Representative
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
ZIP Code
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
B. Date of Rehire (if applicable)
Date (mm/dd/yyyy)
Document Title Document Number
Expiration Date (if any) (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes
continuing employment authorization in the space provided below.
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if
the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Name of Employer or Authorized Representative
LISTS OF ACCEPTABLE DOCUMENTS
All documents must be UNEXPIRED
Employees may present one selection from List A
or a combination of one selection from List B and one selection from List C.
LIST A
2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-551)
1. U.S. Passport or U.S. Passport Card
3. Foreign passport that contains a
temporary I-551 stamp or temporary
I-551 printed notation on a machine-
readable immigrant visa
4. Employment Authorization Document
that contains a photograph (Form
I-766)
5. For a nonimmigrant alien authorized
to work for a specific employer
because of his or her status:
Documents that Establish
Both Identity and
Employment Authorization
6. Passport from the Federated States
of Micronesia (FSM) or the Republic
of the Marshall Islands (RMI) with
Form I-94 or Form I-94A indicating
nonimmigrant admission under the
Compact of Free Association Between
the United States and the FSM or RMI
b. Form I-94 or Form I-94A that has
the following:
(1) The same name as the passport;
and
(2) An endorsement of the alien's
nonimmigrant status as long as
that period of endorsement has
not yet expired and the
proposed employment is not in
conflict with any restrictions or
limitations identified on the form.
a. Foreign passport; and
For persons under age 18 who are
unable to present a document
listed above:
1. Driver's license or ID card issued by a
State or outlying possession of the
United States provided it contains a
photograph or information such as
name, date of birth, gender, height, eye
color, and address
9. Driver's license issued by a Canadian
government authority
3. School ID card with a photograph
6. Military dependent's ID card
7. U.S. Coast Guard Merchant Mariner
Card
8. Native American tribal document
10. School record or report card
11. Clinic, doctor, or hospital record
12. Day-care or nursery school record
2. ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address
4. Voter's registration card
5. U.S. Military card or draft record
Documents that Establish
Identity
LIST B
OR AND
LIST C
7. Employment authorization
document issued by the
Department of Homeland Security
1. A Social Security Account Number
card, unless the card
includes one of
the following restrictions:
2. Certification of report of birth issued
by the Department of State (Forms
DS-1350, FS-545, FS-240)
3. Original or certified copy of birth
certificate issued by a State,
county, municipal authority, or
territory of the United States
bearing an official seal
4. Native American tribal document
6. Identification Card for Use of
Resident Citizen in the United
States (Form I-179)
Documents that Establish
Employment Authorization
5. U.S. Citizen ID Card (Form I-197)
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION
(1) NOT VALID FOR EMPLOYMENT
Page 3 of 3
Form I-9 10/21/2019
Examples of many of these documents appear in the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
EE# /Union
Reason for Change: ____Marriage/Divorce (Date:
)
Effective Date: _________________
(Required) ____ Address Change / Phone Number Change
____ Name Change
____ New Hire / Rehire
____ Emergency Contact Information Change
Employee Name:
SSN
(Last 5 digits)
Legal Name (as it appears on your SS Card) Emergency Contact Information
First Name:
Middle
Initial:
Last
Name:
Maiden
Name:
Prefix Circle One: Mr. Mrs. Ms. Miss Dr. Other_____
Preferred
Name:
Note: Please provide Medical ID number if your
benefits need to be changed:
Please note that Name change requests require a copy of the legal documents
verifying your name change. Acceptable forms of documentation include:
marriage license, divorce decree/court order AND an updated Soc Sec Card
Name:
Relationship:
Address:
City:
State:
Zip:
Home
Number: Preferred
Cell Number: Preferred
Work Number: Preferred
ALL EMPLOYEES MUST HAVE AN EMERGENCY CONTACT ON FILE. PLEASE
BE SURE TO LIST AN EMERGENCY CONTACT.
PERMANENT STREET ADDRESS (Required – No
PO Boxes please):
Address 1:
Address
2:
City:
Zip:
State:
Home
Number:
Cell
Number:
Home
E-Mail Address:
Preferred Mailing Address (if different than
permanent street address) List PO Box Info here:
Address 1:
Address 2:
City:
State:
Zip:
Birth Date:
Gender:
_____ Male ____ Female
Ethnicity:
White
Black or African American
Native Hawaiian/Pacific
Islander
Asian
American Indian or Alaska Native
Two or More Races
Hispanic or Latino
True Marital Status:
Married
Divorced
Single
Separated
Domestic Partner
Widow/Widower
Civil Union
HR/HRIS ONLY:
Validated by_________ / Date____________
WEM: ______ WPH: ______ DBIR: _____
SCN: ______ DOT: ______ DLIC: _____ I9C: ______
Employee Signature: Date:
City of Waterbury
Employee Personal Data Change Form
Address Information (validation required)
Employee Demographic Information
Rev 12-2019
Benefits of Direct Deposit
Quick- with Direct Deposit, your money is electronically transferred into your account and
available to use the morning of the transfer date.
Secure- there is no need to worry about lost, stolen, or misplaced checks. Direct Deposit is more
confidential than paper payments because fewer people are involved in the process.
Convenient- Direct Deposit eliminates having to make deposits in person. If you are not at work
on payday or too busy to get to the bank, your funds are credited to your account.
Reliable- you can be assured your money will be deposited to your account on time, correctly
and confidentially.
To sign up:
Open a bank account or credit union account if you do not already have one.
Complete a Direct Deposit form and return it to the Payroll office in City Hall.
Be sure to check the Net Balance option to put your net pay in your account.
If you would like your pay deposited into multiple accounts, specify a partial amount to
go to each account and be sure to check the Net Balance option for the balance of your
check to be deposited into one of the accounts.
Once you are on Direct Deposit, future pay stubs will be e-mailed to you. Look for an e-
mail from Waterbury.epay@waterburyct.org on payday.
The payment advise will be ab encrypted PDF in the same pay stub format you are used
to now an will be protected by a password combination of the first name with the first
letter capitalized and the rest lowercase, followed by the last 4 digits of your social
security number.
Direct Deposit – now even better with e-Pay
Convenient-Fast-Secure-Reliable-Safe
Thank you for signing up!
If you are interested in direct deposit, the form will be available to you when you drop off your
new hire paperwork. For security reasons, this form is intentially not included in the package.
You will need either a cancelled check or a letter from your bank that provides your banking
information. For more information, please contact Human Resources.
236 Grand Street
(203) 574-6761
Waterbury, CT 06702
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Connecticut
Department of Human Resources
Office of the Civil Service Commission
Confidentiality/ Non Disclosure Agreement
As an employee/contractor for the City of Waterbury, ____________________________Office, I understand that in the course
of my work for the City of Waterbury, _____________________________Office, I may have access to confidential, proprietary
or personal information regarding employees and applicants. As such, confidential information may be verbal, hardcopy,
contained in software, visible on screen displays, in computer or electronic readable forms and format, or otherwise, and may
include, but is not limited to, medical/health, financial, employment, contractual, or institutional data.
I hereby affirm that I will not in any way access, use, remove, disclose, copy, release, sell, loan, alter or destroy any confidential
information except as authorized within the scope of my duties with the City of Waterbury. As an employee/contractor, I must
comply with applicable local, state and federal laws and city policies. I have a duty to safeguard and retain the confidentiality of
all confidential information.
I understand that I will be held responsible for my misuse or unauthorized disclosure of confidential information, including the
failure to safeguard my information access codes or devices. My obligations under this Agreement are effective as of this day
and will continue after my affiliation with City of Waterbury concludes. Violation of this agreement could result in criminal
prosecution under appropriate state and federal laws.
Employee
_
_____________________________________________________________________
Signature Printed Name Date
W
itness
_____________________________________________________________________
Signature Printed Name Date
click to sign
signature
click to edit
Employees: See Employee General Instructions on Page 2. Sign and return Form CT-W4 to your employer. Keep a copy for your records.
1
. Withholding Code: Enter Withholding Code letter chosen from above. ....................... 1.
2. Additional withholding amount per pay period: If any, see instructions. . ..................... 2. $
3. Reduced withholding amount per pay period: If any, see instructions. ........................ 3. $
Form
CT-W4
Employee’s Withholding Certicate
Department of Revenue Services
State of Connecticut
(Rev. 12/20)
Eective January 1, 2021
Employee Instructions
• Read the instructions on Page 2 before completing this form.
• Select the ling status you expect to report on your Connecticut
income tax return. See instructions.
• Choose the statement that best describes your gross income.
• Enter the Withholding Code on Line 1 below.
Check if you are claiming
the MSRRA exemption
and enter state of legal
residence/domicile:
_____________________
Employers: See Employer Instructions, on Page 2.
Complete this form in blue or black ink only.
Declaration: I declare under penalty of law that I have examined this certicate and, to the best of my knowledge and belief, it is true, complete, and
correct. I understand the penalty for reporting false information is a ne of not more than $5,000, imprisonment for not more than ve years, or both.
Is this a new or rehired employee?
No
Yes
Enter date hired:
mm/dd/yyyy
* If you are claiming the Military Spouses Residency Relief Act (MSRRA) exemption, see instructions on Page 2.
Our expected combined annual gross income is less than or
equal to $24,000 or I am claiming exemption under the Military
E
Spouses Residency Relief Act (MSRRA)* and no withholding
is necessary.
My spouse is employed and our expected combined annual
gross income is greater than $24,000 and less than or equal A
to $100,500. See Certain Married Individuals, Page 2.
My spouse is not employed and our expected combined
C
annual gross income is greater than $24,000.
My spouse is employed and our expected combined
D
annual gross income is greater than $100,500.
I have signicant nonwage income and wish to avoid having
D
too little tax withheld.
I am a nonresident of Connecticut with substantial other income.
D
Withholding
Code
My expected annual gross income is less than or equal to
$24,000 or I am claiming exemption under the MSRRA* and
E
no withholding is necessary.
My expected annual gross income is greater than $24,000.
C
I have signicant nonwage income and wish to avoid having too
D
little tax withheld.
I am a nonresident of Connecticut with substantial other income.
D
Withholding
Code
Qualifying Widow(er)
Married Filing Jointly
My expected annual gross income is less than or equal to
$12,000 or I am claiming exemption under the MSRRA* and
E
no withholding is necessary.
My expected annual gross income is greater than $12,000. A
I have signicant nonwage income and wish to avoid having
D
too little tax withheld.
I am a nonresident of Connecticut with substantial other income.
D
Withholding
Code
My expected annual gross income is less than or equal to
E
$15,000 and no withholding is necessary.
My expected annual gross income is greater than $15,000.
F
I have signicant nonwage income and wish to avoid having
D
too little tax withheld.
I am a nonresident of Connecticut with substantial other income.
D
Withholding
Code
My expected annual gross income is less than or equal to
E
$19,000 and no withholding is necessary.
My expected annual gross income is greater than $19,000.
B
I have signicant nonwage income and wish to avoid having
D
too little tax withheld.
I am a nonresident of Connecticut with substantial other income.
D
Withholding
Code
Married Filing Separately
Single
Head of Household
First name Ml Last name Social Security Number
Home address (number and street, apartment number, suite number, PO Box)
City/town State ZIP code
Employee’s signature Date
Employer’s business name Federal Employer Identication Number
Employer’s business address
City/town State ZIP code
Contact person Telephone number
– –
Form CT-W4 (Rev. 12/20)
Page 2 of 2
Form CT-W4 Instructions
Employee General Instructions
Form CT-W4, Employee’s Withholding Certicate, provides your
employer with the necessary information to withhold the correct
amount of Connecticut income tax from your wages to ensure that
you will not be underwithheld or overwithheld.
You are required to pay Connecticut income tax as income is earned
or received during the year. You should complete a new Form CT-W4
at least once a year or if your tax situation changes.
If your circumstances change, such as you receive a bonus or your
ling status changes, you must furnish your employer with a new
Form CT-W4 within ten days of the change.
Gross Income
For Form CT-W4 purposes, gross income means all income from
all sources, whether received in the form of money, goods, property,
or services, not exempt from federal income tax, and includes any
additions to income from Schedule 1 of Form CT-1040, Connecticut
Resident Income Tax Return or Form CT-1040NR/PY, Connecticut
Nonresident and Part‑Year Resident Income Tax Return.
Filing Status
Generally, the ling status you expect to report on your Connecticut
income tax return is the same as the ling status you expect to report
on your federal income tax return. However, special rules apply to
married individuals who le a joint federal return but have a dierent
residency status. Nonresidents and part-year residents should see
the instructions to Form CT-1040NR/PY.
Check Your Withholding
You may be underwithheld if any of the following apply:
• You have more than one job;
• You qualify under Certain Married Individuals; or
• You have substantial nonwage income.
If you are underwithheld, you should consider adjusting your
withholding or making estimated payments using Form CT-1040ES,
Estimated Connecticut Income Tax Payment Coupon for Individuals.
You may also select Withholding Code “D” to elect the highest level
of withholding.
If you owe $1,000 or more, after subtracting from your Connecticut
income tax the amount withheld from your income for the prior taxable
year, and any PE Tax Credit, you may be subject to interest on the
underpayment at the rate of 1% per month or fraction of a month.
To help determine if your withholding is correct, see Informational
Publication 2021(7), Is My Connecticut Withholding Correct?
Certain Married Individuals
If you are a married individual ling jointly and you and your spouse
both select Withholding Code “A,” you may have too much or too
little Connecticut income tax withheld from your pay. This is because
the phase-out of the personal exemption and credit is based on your
combined incomes. The withholding tables cannot reect your exact
withholding requirement without considering the income of your spouse.
To minimize this problem, and determine if you need to adjust your
withholding using Line 2 or Line 3, see IP 2021(7).
Nonresident Employees Working Partly Within and Partly
Outside of Connecticut
If you work partly within and partly outside of Connecticut for
the same employer, you should also complete Form CT-W4NA,
Employee’s Withholding or Exemption Certicate - Nonresident
Apportionment, and provide it to your employer. The information on
Form CT-W4NA and Form CT-W4 will help your employer determine
how much to withhold from your wages for services performed within
Connecticut. For Convenience of the Employer Test information, see
Form CT-W4NA. To obtain Form CT-W4NA, visit the Department of
Revenue Services (DRS) website at portal.ct.gov/DRS or request
the form from your employer. Any nonresident who expects to have no
Connecticut income tax liability should choose Withholding Code “E.”
Armed Forces Personnel and Veterans
If you are a Connecticut resident, your armed forces pay is subject
to Connecticut income tax withholding unless you qualify as a
nonresident for Connecticut income tax purposes. If you qualify as
a nonresident, you may request that no Connecticut income tax be
withheld from your armed forces pay by entering Withholding Code “E”
on Line 1.
Military Spouses Residency Relief Act (MSRRA)
If you are claiming an exemption from Connecticut income tax under
the MSRRA, you must provide your employer with a copy of your
military spouse’s Leave and Earnings Statement (LES) and a copy
of your military dependent ID card.
See Informational Publication 2019(5), Connecticut Income Tax
Information for Armed Forces Personnel and Veterans.
Employer Instructions
For any employee who does not complete Form CT-W4, you are required
to withhold at the highest marginal rate of 6.99% without allowance
for exemption. You are required to keep Form CT-W4 in your les for
each employee. See Informational Publication 2021(1), Connecticut
Employer’s Tax Guide, Circular CT, for complete instructions.
Report Certain Employees Claiming Exemption From Withholding
to DRS
Employers are required to le copies of Form CT-W4 with DRS for
certain employees claiming “E” (no withholding is necessary). See
IP 2021(1). Mail copies of Forms CT-W4 meeting the conditions listed
in IP 2021(1) under Reporting Certain Employees to:
Department of Revenue Services
PO Box 2931
Hartford CT 06104-2931
Report New and Rehired Employees to the Department of Labor
New employees are workers not previously employed by your
business, or workers rehired after having been separated from your
business for more than sixty consecutive days.
Employers with oces in Connecticut or transacting business in
Connecticut are required to report new hires to the Department of
Labor (DOL) within 20 days of the date of hire.
New hires can be reported by:
• Using the Connecticut New Hire Reporting website at
www.ctnewhires.com;
• Faxing copies of completed Forms CT-W4 to 800-816-1108; or
• Mailing copies of completed Forms CT-W4 to:
Connecticut Department of Labor
Oce of Research, CT-W4
200 Folly Brook Blvd
Wetherseld CT 06109
For more information on DOL requirements or for alternative reporting
options, visit the DOL website at www.ctdol.state.ct.us or call DOL
at 860-263-6310.
For More Information
Call DRS Monday through Friday, 8:30 a.m. to 4:30 p.m. at:
• 800-382-9463 (Connecticut calls outside the Greater Hartford
calling area only); or
• 860-297-5962 (from anywhere).
TTY, TDD, and Text Telephone users only may transmit inquiries
anytime by calling 860-297-4911. Taxpayers may also call 711 for
relay services. A taxpayer must tell the 711 operator the number he or
she wishes to call. The relay operator will dial it and then communicate
using a TTY with the taxpayer.
Forms and Publications
Visit the DRS website at portal.ct.gov/DRS to download and print
Connecticut tax forms and publications.
Form W-4
(Rev. December 2020)
Department of the Treasury
Internal Revenue Service
Employee’s Withholding Certificate
▶
Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
▶
Give Form W-4 to your employer.
▶
Your withholding is subject to review by the IRS.
OMB No. 1545-0074
2021
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
▶
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 estimator at www.irs.gov/W4App, 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 . . . . .
▶
TIP: To be accurate, submit a 2021 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 total 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
▶
$
Multiply the number of other dependents
by $500 . . . .
▶
$
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.
▲
Employee’s signature (This form is not valid unless you sign it.)
▲
Date
Employers
Only
Employer’s name and address First date of
employment
Employer identification
number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2021)
Form W-4 (2021)
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, Tax Withholding and Estimated Tax.
Exemption from withholding. You may claim exemption
from withholding for 2021 if you meet both of the following
conditions: you had no federal income tax liability in 2020
and you expect to have no federal income tax liability in
2021. You had no federal income tax liability in 2020 if (1)
your total tax on line 24 on your 2020 Form 1040 or 1040-SR
is zero (or less than the sum of lines 27, 28, 29, and 30), 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 2021 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 1(a), 1(b),
and 5. Do not complete any other steps. You will need to
submit a new Form W-4 by February 15, 2022.
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 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.
▲
!
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. This step 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 2021 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 (2021)
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 2021 itemized deductions (from Schedule A (Form 1040)). Such deductions
may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to
$10,000), and medical expenses in excess of 7.5% of your income . . . . . . . . . . . . 1
$
2 Enter:
{
• $25,100 if you’re married filing jointly or qualifying widow(er)
• $18,800 if you’re head of household
• $12,550 if you’re single or married filing separately
}
. . . . . . . . 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. 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 Part II of Schedule 1 (Form 1040)). 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 (2021)
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 $190 $850 $890 $1,020 $1,020 $1,020 $1,020 $1,020 $1,100 $1,870 $1,870
$10,000 - 19,999
190 1,190 1,890 2,090 2,220 2,220 2,220 2,220 2,300 3,300 4,070 4,070
$20,000 - 29,999 850 1,890 2,750 2,950 3,080 3,080 3,080 3,160 4,160 5,160 5,930 5,930
$30,000 - 39,999
890 2,090 2,950 3,150 3,280 3,280 3,360 4,360 5,360 6,360 7,130 7,130
$40,000 - 49,999
1,020 2,220 3,080 3,280 3,410 3,490 4,490 5,490 6,490 7,490 8,260 8,260
$50,000 - 59,999 1,020 2,220 3,080 3,280 3,490 4,490 5,490 6,490 7,490 8,490 9,260 9,260
$60,000 - 69,999
1,020 2,220 3,080 3,360 4,490 5,490 6,490 7,490 8,490 9,490 10,260 10,260
$70,000 - 79,999
1,020 2,220 3,160 4,360 5,490 6,490 7,490 8,490 9,490 10,490 11,260 11,260
$80,000 - 99,999 1,020 3,150 5,010 6,210 7,340 8,340 9,340 10,340 11,340 12,340 13,260 13,460
$100,000 - 149,999
1,870 4,070 5,930 7,130 8,260 9,320 10,520 11,720 12,920 14,120 15,090 15,290
$150,000 - 239,999
2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,230 16,190 16,400
$240,000 - 259,999 2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,830 14,030 15,270 17,040 18,040
$260,000 - 279,999
2,040 4,440 6,500 7,900 9,230 10,430 11,630 12,870 14,870 16,870 18,640 19,640
$280,000 - 299,999
2,040 4,440 6,500 7,900 9,230 10,470 12,470 14,470 16,470 18,470 20,240 21,240
$300,000 - 319,999 2,040 4,440 6,500 7,940 10,070 12,070 14,070 16,070 18,070 20,070 21,840 22,840
$320,000 - 364,999
2,720 5,920 8,780 10,980 13,110 15,110 17,110 19,110 21,190 23,490 25,560 26,860
$365,000 - 524,999
2,970 6,470 9,630 12,130 14,560 16,860 19,160 21,460 23,760 26,060 28,130 29,430
$525,000 and over
3,140 6,840 10,200 12,900 15,530 18,030 20,530 23,030 25,530 28,030 30,300 31,800
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 $440 $940 $1,020 $1,020 $1,410 $1,870 $1,870 $1,870 $1,870 $2,030 $2,040 $2,040
$10,000 - 19,999
940 1,540 1,620 2,020 3,020 3,470 3,470 3,470 3,640 3,840 3,840 3,840
$20,000 - 29,999 1,020 1,620 2,100 3,100 4,100 4,550 4,550 4,720 4,920 5,120 5,120 5,120
$30,000 - 39,999
1,020 2,020 3,100 4,100 5,100 5,550 5,720 5,920 6,120 6,320 6,320 6,320
$40,000 - 59,999
1,870 3,470 4,550 5,550 6,690 7,340 7,540 7,740 7,940 8,140 8,150 8,150
$60,000 - 79,999 1,870 3,470 4,690 5,890 7,090 7,740 7,940 8,140 8,340 8,540 9,190 9,990
$80,000 - 99,999
2,000 3,810 5,090 6,290 7,490 8,140 8,340 8,540 9,390 10,390 11,190 11,990
$100,000 - 124,999
2,040 3,840 5,120 6,320 7,520 8,360 9,360 10,360 11,360 12,360 13,410 14,510
$125,000 - 149,999 2,040 3,840 5,120 6,910 8,910 10,360 11,360 12,450 13,750 15,050 16,160 17,260
$150,000 - 174,999
2,220 4,830 6,910 8,910 10,910 12,600 13,900 15,200 16,500 17,800 18,910 20,010
$175,000 - 199,999
2,720 5,320 7,490 9,790 12,090 13,850 15,150 16,450 17,750 19,050 20,150 21,250
$200,000 - 249,999 2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$250,000 - 399,999
2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,820 20,930 22,030
$400,000 - 449,999
2,970 5,880 8,260 10,560 12,860 14,620 15,920 17,220 18,520 19,910 21,220 22,520
$450,000 and over
3,140 6,250 8,830 11,330 13,830 15,790 17,290 18,790 20,290 21,790 23,100 24,400
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 $820 $930 $1,020 $1,020 $1,020 $1,420 $1,870 $1,870 $1,910 $2,040 $2,040
$10,000 - 19,999
820 1,900 2,130 2,220 2,220 2,620 3,620 4,070 4,110 4,310 4,440 4,440
$20,000 - 29,999 930 2,130 2,360 2,450 2,850 3,850 4,850 5,340 5,540 5,740 5,870 5,870
$30,000 - 39,999
1,020 2,220 2,450 2,940 3,940 4,940 5,980 6,630 6,830 7,030 7,160 7,160
$40,000 - 59,999
1,020 2,470 3,700 4,790 5,800 7,000 8,200 8,850 9,050 9,250 9,380 9,380
$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,850 11,050 11,250 11,520 12,320
$80,000 - 99,999
1,880 4,280 5,710 7,000 8,200 9,400 10,600 11,250 11,590 12,590 13,520 14,320
$100,000 - 124,999
2,040 4,440 5,870 7,160 8,360 9,560 11,240 12,690 13,690 14,690 15,670 16,770
$125,000 - 149,999 2,040 4,440 5,870 7,240 9,240 11,240 13,240 14,690 15,890 17,190 18,420 19,520
$150,000 - 174,999
2,040 4,920 7,150 9,240 11,240 13,290 15,590 17,340 18,640 19,940 21,170 22,270
$175,000 - 199,999
2,720 5,920 8,150 10,440 12,740 15,040 17,340 19,090 20,390 21,690 22,920 24,020
$200,000 - 249,999 2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$250,000 - 349,999
2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,880 24,980
$350,000 - 449,999
2,970 6,470 9,000 11,390 13,690 15,990 18,290 20,040 21,340 22,640 23,900 25,200
$450,000 and over 3,140 6,840 9,570 12,160 14,660 17,160 19,660 21,610 23,110 24,610 26,050 27,350
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Completed 21 March 2021

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