ATHENS "Y" CAMPS 2021 New Hire Checklist
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ATHENS “Y” CAMPS 2021 New Hire Checklist Name: ____________________________________ DEPARTMENT (please circle) (AYC- BOYS CAMP) (CAMP CHATTOOGA –GIRLS) The following information must be completely filled out and included in each new employee’s hire packet. Keep your packets together in the following order. Please check off each item and sign below, returning the entire packet with the checklist to the Athens Y Camps Office. ¨ Application for Employment (Completed On-Line) ¨ Contracted Signed (Emailed form Campsite) ¨ General Rules of Conduct ¨ Employee Personal Information Form ¨ Terms of Employment Agreement ¨ Personnel Policy Acknowledgement ¨ Safety Rules & Practices Acknowledgement ¨ Conflict of Interest & Ethics Statement ¨ Code of Conduct ¨ Drug Free Workplace Statement ¨ Child Abuse Statement & Agreement ¨ YMCA & Athens Y Camps Safety Policy ¨ Criminal History/DMV Background Consent Form ¨ W-4 Form (Under Employment Package on web site) ¨ I-9 Form (Under Employment Package on web site) ¨ Georgia Withholding Form (Under Employment Package on web site) ¨ Medical Form (Under Forms on Web Site Health form) ¨ Copy of Insurance Card (Please Include) ¨ Copy of Driver License (Please Include) ¨ Copy of Social Security or Passport (Please Include) ¨ Copy of Life Guard Certification our any other (Please Include) ¨ Co-vid 19 Paperwork (If Needed) 1
Please Double Check Make Sure Application is completed. All Questions and the 2 Places that need Signature and Date. 2
Blank Page is to be Replaced by A Printed and Signed Contract Emailed from Campsite. Please List Shirt Size on Contract. 3
General Rules of Conduct Staff Expectations and Requirements: 1) Put Jesus first in every area of your life and have a desire to share this faith with others. 2) No partaking of illegal drugs at any time while in the employ of the Athens YMCA Camps. Any substantiated report of such action on the grounds or out of camp (this includes nights out and weekend breaks) will result in immediate dismissal. 3) No partaking of alcoholic beverages at any time while in the employ of the Athens YMCA Camps. Any substantiated report of such action on the grounds or out of camp (this includes nights out and weekend breaks) result in punishment, such as immediate dismissal or pay deduction, as determined by the camp director. 4) No pornographic material of any type is allowed on campgrounds. This includes staff members' vehicles! Any substantiated report of possession of said material is grounds for immediate dismissal. 5) No smoking, dipping, or chewing of any tobacco products is allowed while in the employ of the Athens YMCA Camps. Any substantiated report of such action on the grounds (this includes staff members' cars) will result in punishment. If action persists, dismissal will follow. 6) No use of obscenity or profanity will be tolerated. Any substantiated report of such language will result in punishment. If action persists, dismissal will follow. 7) No articles of clothing, posters, music, etc. with satanic signs or scenes, offensive designs, unwholesome language or lyrics, or advertisement of alcoholic beverages are permitted on the campgrounds. If any of these are seen in camp, they will be confiscated. 8) No reading material or any other printed media that could be construed as inappropriate at a Christian camp will be permitted on the premises. If any of these are seen in camp, they will be confiscated. 9) Personal appearance must be kept neat and maintained while serving as a camp staff member. Tattoos must be concealed and body piercing must be removed at all times while on the campgrounds (Girl’s camp staff members may have their ears pierced as the only exception to this rule). Boy’s camp staff must maintain a haircut throughout the summer that is not over the ears or shirt collar. Clothing should be conservative in nature: girls should wear only one piece bathing suits, shorts should be a reasonable length – not too short and sleeveless shirts should at least have a strap width of two fingers. These guidelines should be adhered to at all times while on camp property and camp trips. Modesty during time off away from camp is appreciated as well. 10) Staff members are not permitted to fraternize with members of the opposite sex except during staff time off and approved camp functions. Staff members are expected to hold to a Biblical standard of sexual morality during their employment. Inappropriate relationships between staff members of the same sex and/or campers are not permitted and any substantiated report of such activity will result in immediate dismissal. 11) Staff may bring music players to be used ONLY in between sessions when campers have left. Music that has unwholesome language or lyrics is not permitted and will be confiscated. No headphones while on duty. All staff members are expected to abide by these requirements. If you cannot commit to these expectations DO NOT return your staff contract for employment as our camps will not be the best fit for you. Signature __________________________________ Date _____________________________ 4
Athens Y Camps Employee Personal Information Form Employee Name: ___________________________________ Hire Date: __________________________ Branch: ATHENS Y CAMPS (Payroll information is entered from this page) To be completed by employee: EMPLOYEE TYPE: PSEASONAL EMPLOYEE Employee Name: (Last) __________________________ (First) _________________________ (M) ______________ StreetAddress_______________________________________________________ City _________________________ State ______________Zip______________ Telephone (Home): ____________________ (Cell): ______________________ Social Security________________________________ Date of Birth _____/____ /_____ Sex (M/F) _______________ Marital Status: £Single £Married Highest Grade (1-11) ____________________ High School (Grad/GED): __________________ Highest College Year: ____________________ Degree Attained: _______________________ 5
Athens Y Camps Term of Employment Agreements: 1. The YMCA will provide Workman’s Compensation Insurance and FICA Medicare as provided by law. 2. The Employee agrees to fulfill the duties listed in the attached job description. 3. The Employee agrees to the following Code of Ethics: • Relate to members/program participants in a manner, which is courteous, enthusiastic, and reflective of an attitude of concern at all times. • Strive to be a role model in language, dress, attitude, and conduct. • Notify the Athens Y Camps in advance, when it is unavoidable to miss work or be late. • Never act as an agent of the Athens Y Camps regarding business transactions or media inquiries outside the limits of the job description. • Read and sign the Code of Conduct regarding Child Abuse 4. Full-time employees working 40 hours per week are eligible for the full benefit package as provided in the YMCA and Athens Y Camps Personnel Policy. I understand the above statements and agree to work for the Athens Y Camps under this Employee Agreement. I understand that violation of any of the conditions or statements in this document is grounds for dismissal. I understand this job is contingent on sufficient enrollment. . Employee Signature: Date: Supervisor’s Signature: Athens Y Camps Date: 6
Athens Y Camps Personnel Policy Acknowledgement I, ________________________________ have received and reviewed a copy of the Athens YMCA Inc. Personnel Policy and have either read it or had it read to me. I understand that any provisions of this policy may be revised at any time and that the policy does not guarantee me any specific policies, procedures, rules, benefits, or length of employment. Finally, I agree to obey and abide by its contents. Employee Signature: Date: Supervisor’s Signature: Athens Y Camps Date: 7
Athens Y Camps Safety Rules & Practices Acknowledgement Emergency Procedures and Safety Practice Guidelines Acknowledgement I hereby acknowledge that I have received and read the emergency procedures and safety practice guidelines of the Athens Y CAMPS. I have had an opportunity to have all aspects of this material fully explained. I also understand that I must abide by the safety rules and practices as a condition of initial and/or continued employment, and any violation may result in disciplinary action up to and including discharge. I ALSO UNDERSTAND THAT THE EMERGENCY PROCEDURES AND SAFETY PRACTICE GUIDELINES AND ANY RELATED DOCUMENTS ARE NOT INTENDED TO CONSTITUTE A CONTRACT BETWEEN THE COMPANY AND ME. THE UNDERSIGNED FURTHER STATES THAT HE OR SHE HAS READ THE FORGOING ACKNOWLEDGEMENT AND KNOWS THE CONTENTS THEREOF AND SIGNS THE SAME OF HIS OR HER OWN FREE WILL. Employee Signature: Date: 8
Athens Y Camps Policy Regarding Conflict of Interest & Ethics Statement The Athens YMCA, and Athens Y Camps, expects all employees to avoid activities, which create a conflict of interest with their responsibility to this organization. The organization also expects its employees to observe the highest moral and ethical standards in any dealings in which they represent the organization. The organization recognizes and respects each employee’s right to privacy and to engage in personal activities outside the scope of his or her employment with the organization. Each employee also has an obligation, however, to refrain from activities which conflict with the organization’s operation. Any of the following may be considered a conflict and therefore must be disclosed by the employee in an effort to resolve the potential conflict. Potential conflict of interest includes but not limited to: outside employment, provision of services for competitors or clients, outside business interests, accepting gifts from companies/supplies/individuals doing business with the organization promoting personal business property during hours of organization employment. Employees are required to report and disclose any of these or other areas, which may constitute a conflict of interest. This is to certify that I have read and understand this policy and have disclosed outside employment or businesses in which I am involved. I understand if at any time I become involved in any outside employment or business, I must report it immediately. Employee Signature: Date: 9
Athens Y Camps Code of Conduct 1. Put Jesus first in every area of your life and have a desire to share this faith with others. 2. In order to protect the Athens Y Camps staff, volunteers, and program participants- at no time during an Athens Y Camps program may a staff member be alone with a single child where others cannot observe them. As staff supervise children, they should space themselves in a way that other staff can see them. 3. Staff shall never leave a child unsupervised. 4. Restroom observation on trips: Staff will make sure the restroom is not occupied by suspicious or unknown individuals before allowing children to use the facilities. Staff will stand in the doorway while children are using the restroom. This policy allows privacy for the children and protection for the staff (not being alone with a child). If the staff is assessing younger children, doors to the facility must remain open. No child, regardless of age should ever enter a bathroom alone on a field trip. Always send children in pairs, and whenever possible, a staff. 5. Staff should conduct or supervise private activities in pairs— putting on bathing suits, taking showers, etc. When this is not feasible, staff should be positioned so that they are visible to others. 6. Staff should not abuse children including • Physical Abuse-strike, spank, shake, etc. • Verbal Abuse- humiliate, degrade, threaten, etc. • Sexual Abuse- inappropriate touch or verbal exchange • Mental Abuse- shaming, withholding food, water, basic care, etc. 7. Staff must use positive techniques of guidance, including redirection, positive reinforcement and encouragement rather than competition, comparison or criticism. Staff will have age appropriate expectations and set up guidelines and environments that minimize the need for discipline. Physical restraint is used only in pre-determined situations (necessary to protect the child or other children from harm), is only administered in a prescribed manner and must be documented in writing. 8. Staff will conduct a health check of each child, each day, as they enter the program, noting any fever, bumps, bruises, burns, etc. Questions or comments will be addressed to the parent or child in a non-threatening way. Any questionable marks or responses will be documented. 9. Staff will respond to children with respect and consideration and treat all children equally regardless of sex, race, religion, or culture. Staff will respect children’s rights to not be touched in ways that make them feel uncomfortable, and their right to say no. Children are not to be touched in areas of their bodies that would be covered by a bathing suit. 10. While the Athens Y Camps does not discriminate against an individual’s lifestyle, it does require that in the Performance of their job, they will abide by the standards of conduct set forth by the YMCA and Athens Y Camps. 10
11. No partaking of alcoholic beverages at any time while in the employ of the Athens Y Camps. Any substantiated report of such action on the grounds or out of camp (this includes nights out and weekend breaks) result in punishment, such as immediate dismissal or pay deduction, as determined by the camp director. 12. No smoking, dipping, or chewing of any tobacco products are allowed while under employment of the Athens Y Camps. Any substantiated report of such action on the grounds (this includes staff member’s vehicles) will result in punishment. If action persists, dismissal will follow. 13. No use of obscenity or profanity will be tolerated. Any substantiated report of such language will result in punishment. If action persists, dismissal will follow. 14. Staff must be free of physical and physiological conditions that might adversely affect any individual’s PHYSICAL or mental health. 15. Staff will portray a positive role model for youth by maintaining an attitude of respect, loyalty, PATIENCE, courtesy, tact and maturity. 16. Staff may not be alone with children from the Athens Y Camps programs outside of the Athens Y Camps. This includes babysitting, sleepovers, and inviting children to your home. Any exceptions require a written explanation before the fact and are subject to the Executive Director’s approval. 17. Staff is not to transport children in their own vehicles. 18. Staff members are not permitted to fraternize with member of the opposite sex except during staff time off and approved camp functions. Staff members are expected to hold to a Biblical standard of sexual morality during their employment. Inappropriate relationships between staff members of the same sex and/or campers are not permitted. Any substantiated report of such activity will result in immediate dismissal. 19. Under no circumstances should staff release children to anyone other than the authorized parent, guardian or other adult authorized by the parent or guardian (written parent authorization must be on file with the Athens Y Camps). 20. Staff is required to read and sign all policies related to identifying, documenting, and reporting child abuse and attend training on the subject, as instructed by a supervisor. 21. Personal appearance must be kept neat and maintained while serving as a camp staff member. Tattoos must be concealed and body piercing must be removed at all times while on the campgrounds (girl’s camp staff members may have their ears pierced as the only exception to the rule.) Boy’s camp staff must maintain a haircut throughout the summer that is not over the ears or shirt collar. Clothing should be conservative in nature: girls should wear only one piece swim suits, shorts should be a reasonable length – not too short and sleeveless shirts should at least have a strap width of two fingers. These guidelines should be adhered to at all times while on camp property and camp trips. Modesty during time off away from camp is appreciated as well. 22. No pornographic material of any type is allowed on campgrounds. This includes staff members’ vehicles. Any substantiated report of possession of said material is grounds for immediate dismissal. 23. Music that has unwholesome language of lyrics is not permitted and will be confiscated. No headphones while on duty. 11
24. No partaking of illegal drugs at any time while in the employ of the Athens Y Camps. Any substantiated report of such action on the grounds or out of camp (this includes nights out and weekend breaks) will result in immediate dismissal. All staff members are expected to abide by these requirements. If you cannot commit to these expectations DO NOT return your staff contract for employment as our camps will not be the best fit for you. I understand that any violation of this Code of Conduct may result in my termination from employment with the Athens YMCA or Athens Y Camps immediately. Employee Signature: Date: 12
Athens YMCA and Athens Y Camps Drug Free Workplace Statement The Board of Directors of the Athens YMCA believes it is the right of every employee and volunteer to work or volunteer in an environment void of controlled substances (drugs) or alcohol. Further, the Board recognizes that controlled drug and alcohol use at the work site, YMCA property, on Athens Y Camps property, or at satellite facilities seriously impairs not only his/her effectiveness on the job, but also his/her own health. Therefore, it is our resolve to be officially known to all as Drug Free Workplace. Each employee and the public are hereby notified by this policy that the unlawful manufacturer, dispensing, possession, distribution, or use of controlled substance or alcohol is strictly prohibited at any and all work sites or work related functions or as a part of any YMCA activity, or any function held on YMCA property. Any employee or volunteer of the YMCA shall be subject to such discipline as the President/CEO and Board of Managers/Directors determine. Penalties will include, but are not limited to: verbal and/or written reprimands, suspension from duty, requirement to participate satisfactorily in a substance abuse or rehabilitation program, dismissal from duty, and criminal prosecution. Employees suspected of possessing, selling or distributing drugs will be reported to the proper law enforcement authorities. Should an employee be in possession of an illegal controlled substance or involved in any substance abuse on the job, that employee would be subject to disciplinary actions, which may result in immediate discharge. Should an employee be injured on the job, the YMCA and Athens Y Camps reserves the right to have that employee drug tested to determine if substance abuse cause the accident. As a condition of employment with the Athens YMCA, or Athens Y Camps, I agree to abide by the terms and conditions of this policy as listed in the above paragraphs. Employee Signature: Date: 13
Athens YMCA &Athens Y Camps Child Abuse Statement & Agreement For more than 140 years the YMCA has had as its principle concerns the growth and development of men, women, boys, girls, and families. Through programs of health and fitness, aquatics, sports, camping, parent/child, family programs, and childcare, the YMCA is responsible to the needs of the children and families of today. Many changes have occurred in the lives of children and families today. Some of these changes are positive, however, the alarming increase in child abuse is of particular concern to the YMCA. Throughout its history, the YMCA has been a strong advocate for the child and children’s rights. It is most appropriate that mistreatment or neglect of children and the resulting severe effects would be of primary concern to the YMCA. Based upon its concern for children, parents and YMCA staff, the following standards related to reporting, procedures, staffing, standards, code of conduct, and resources for parents and children have been developed. CHILD ABUSE Child Abuse is repeated mistreatment or neglect of a child by parent(s) or others resulting in injury or harm. Child abuse may be physical, verbal, emotional, or sexual. Its effects are severe-emotional and physical handicaps, anti-social behavior, and even death. YMCA STANDARDS RELATED TO CHILD ABUSE Reporting Procedures 1. At the first report or suspicion of child abuse, the staff or volunteer to whom it has been reported, will immediately inform the CEO or your immediate supervisor. 2. The YMCA will make a report to the appropriate local law enforcement body and request that the situation be investigated. 3. In the event the reported incident or suspicion involves an employed staff person or program volunteer, the responsible executive will, without exception, suspend the person from all responsibilities. 4. The parent(s) or legal guardian of the child or children involved will be promptly notified. 14
5. Regardless of where the incident or alleged offense takes place, if an employed person is involved, it will be considered as job related. 6. Reinstatement of a staff person or program volunteer will occur only after all allegations have been cleared to the satisfaction of the CEO or your immediate supervisor. All staff members and volunteers must be sensitive to the need for confidentiality in handling of information in this area and are therefore instructed to only discuss matters pertaining to abuse or suspected abuse with the CEO. 7. YMCA staff and volunteers are not too contact children or parents involved in child abuse incidences without permission of the CEO. 8. All employed staff will be required to sign a statement, provided by their employer that they are aware that they are required by law to report known or suspected instances of child abuse and that not doing so is considered a misdemeanor. They must further acknowledge have read these YMCA standards. Staffing Procedures and Code of Conduct 1. Reference checks will be conducted, documented and filed on all employees prior to employment. 2. Staff and program leaders working directly with children will be required to be fingerprinted and screened by the appropriate law enforcement agency. 3. Parents of program participants will be informed in writing of procedures for communicating information concerning their child’s program experience and relationship with YMCA staff. 4. In order to protect YMCA and Athens Y Camps staff and program participants-at no time during a YMCA, or camp, program may a staff person be alone with a single child where they cannot be observed by other staff. 5. At no time may children be unsupervised in bathrooms, locker rooms, or showers. 6. YMCA and Athens Y Camps staff may not relate to children in YMCA programs outside of approved YMCA or camp activities, i.e. babysitting, weekend trips, etc. 7. YMCA staff may not date program participants under the age of 21 years of age. 8. YMCA and Athens Y Camps staff or volunteers may not discipline children by use of physical punishment or by failing to provide the necessary care. 15
9. YMCA staff or volunteers may not verbally or emotionally abuse or punish children. 10. YMCA staff will under no circumstances release children to anyone other than the authorized parent(s), guardian, or individual authorized by parents in writing. 11. All children will be checked for health and physical condition by a staff member each time they report to a YMCA program, and a report will be made on any sights of physical injury. I have read the YMCA and Athens Y Camps STANDARDS AND STAFF CODE OF CONDUCT RELATED TO CHILD ABUSE. I agree to comply with all points in the document. I am aware that I am required by law to report known or suspected instances of child abuse to my YMCA or Athens Y Camps Supervisor and that not doing so is considered a misdemeanor. I give the YMCA or Athens Y Camps permission to do a check of police records, personal references, former employers, and fingerprints. Employee Signature: Date: Supervisor’s Signature: Athens Y Camps Date: 16
YMCA & Athens Y Camps Safety Policies & Procedures The Athens YMCA and Athens Y Camps are committed to safety and have taken steps to protect you from injury on the job. I. Your compliance is vital for your own protection. Please observe the following rules at all times: 1. No alcohol or drugs should be used on the job at any time. 2. Report all job accidents the same day the accident happens. 3. Obtain authorization from your supervisor for all non-emergency treatments for accidents. 4. Wear seat belts at all times in YMCA and Camp vehicles. 5. Keep the area where you work clean and neat at all times. 6. Do not remove or bypass any guards on any machinery or equipment at any time. 7. Ask you supervisor when you need additional equipment or instructions to get the job done safely. 8. Lift with your legs, not your back, and get assistance with loads over 50 lbs. 9. If your job requires eye protection (such as around pool chlorine) make certain you wear it. 10. Advise your supervisor of any hazardous conditions 11. Follow all other written and spoken safety rules II. General Lifting Reminders: It is impossible to eliminate all lifting from the workplace. The following are examples of lifting activities that may put your back at risk of being injured: • Lifting objects over your head puts extra strain on your lower back and neck • Twisting when lifting an object puts extra strain on your lower back and increases your risk of pulling a muscle • Reaching over an obstacle to lift a load puts extra strain on your lower back • Lifting Preparation • Prior to lifting an object, it is important to plan your lift and the path you are going to take. • Choose the straightest, flattest and clearest path to your destination • Clear the path of all moveable objects • Check the path for rough or slippery surfaces • Check the weight and stability of the object to make sure you can lift it Lifting the Load Lifting the load is what causes most of the back injuries in the workplace. The following are steps to lifting a load safely: • Stand close to the load • Balance yourself with both feet firmly on the floor, shoulder-width apart • Squat down, bending your knees • Keep your back arched 17
• Grip the object firmly with both hands and on opposite corners • Tuck your arms and elbows close to your side • Use your legs to bring you to a standing position • Lift smoothly and under control Carrying the Load Once you have lifted the load, it is important to carry it properly. • Hold the load as close to your body as possible • When lowering the load, bend your knees-not your waist • Move smoothly and under control Lifting alternatives Prior to lifting an object, consider how you can eliminate the lift or do as little lifting as possible. The following are a couple of examples of alternatives to lifting: • Ask a co-worker for help • Use equipment such as a hand truck, hoist, or pushcart Pushing the Load Pushing a load is easier on your back than pulling. When pushing a load, keep these things in mind: • Stay close to the load • Walk up-right—do not lean forward • Use both arms Pulling the Load If you have no other alternative that to pull the load, keep these things in mind: • Face the object • Keep your back straight • Bend your knees • Pull with one smooth motion 18
III. Material Safety Data Sheets (MSDS): The Athens YMCA keeps all MSDS on all chemicals used in/around the YMCA’s facilities. The sheets are kept in a binder in the front office. Please read/refer to the sheets whenever you have questions about a particular chemical the YMCA uses. First Aid and CPR: All YMCA and Athens Y Camps Staff (both full time and part time) are required to be certified in the first aid CPR within 30 days of employment. The certification can be through the Red Cross, American Heart Association or the safety council. The YMCA will periodically host classes at the YMCA. It is the employee’s responsibility to enroll in and complete courses. Employees are responsible for all fees associated with courses. I have read these rules, understand them and will obey them for my own benefit. Employee Signature: Date: Supervisor’s Signature: Athens Y Camps Date: Where injury is caused by the knowing refusal of the employee to use a safety appliance provided by the employer, workers’ compensation benefits can be reduced. 19
Criminal History & DMV Background Consent Form Name:(First) ____________________ (Middle) _______________(Last)_________________ Social Security # ____________________________ Driver License # __________________ State__________ Permanent Address_____________________________________________________ City_____________________________ State ________ Zip _____________ DOB (MM/DD/YYYY) ___________________ I authorize the Athens YMCA Camps to complete a criminal background check including criminal history record, state sex offender registry, and department of motor vehicles checks. Signature: ________________________________________ Date: ___________ Printed Name: __________________________________________ Office Use Only: Date Check Ran Agency Director Approval 20
Form W-4 Employee’s Withholding Certificate Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. OMB No. 1545-0074 (Rev. December 2020) Department of the Treasury Internal Revenue Service Give Form W-4 to your employer. Your withholding is subject to review by the IRS. 2021 (a) First name and middle initial Last name (b) Social security number Step 1: Enter Address Does your name match the Personal name on your social security card? If not, to ensure you get Information City or town, state, and ZIP code 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: Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse Multiple Jobs also works. The correct amount of withholding depends on income earned from all of these jobs. or Spouse Do only one of the following. Works (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: If your total income will be $200,000 or less ($400,000 or less if married filing jointly): Claim Multiply the number of qualifying children under age 17 by $2,000 $ Dependents Multiply the number of other dependents by $500 . . . . $ Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $ Step 4 (a) Other income (not from jobs). If you want tax withheld for other income you expect (optional): this year that won’t have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income . . . . . . . . . . . . 4(a) $ Other Adjustments (b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here . . . . . . . . . . . . . . . . . . . . . 4(b) $ (c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $ Step 5: Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete. Sign Here Employee’s signature (This form is not valid unless you sign it.) Date Employers Employer’s name and address First date of Employer identification employment number (EIN) Only For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2021) 21
Form W-4 (2021) Page 2 General Instructions Specific Instructions Future Developments Step 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to For the latest information about developments related to compute your withholding. Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4. 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 Purpose of Form spouse both work. Complete Form W-4 so that your employer can withhold the Option (a) most accurately calculates the additional tax correct federal income tax from your pay. If too little is you need to have withheld, while option (b) does so with a withheld, you will generally owe tax when you file your tax little less accuracy. return and may owe a penalty. If too much is withheld, you If you (and your spouse) have a total of only two jobs, you will generally be due a refund. Complete a new Form W-4 may instead check the box in option (c). The box must also when changes to your personal or financial situation would be checked on the Form W-4 for the other job. If the box is change the entries on the form. For more information on checked, the standard deduction and tax brackets will be withholding and when you must furnish a new Form W-4, cut in half for each job to calculate withholding. This option see Pub. 505, Tax Withholding and Estimated Tax. is roughly accurate for jobs with similar pay; otherwise, more Exemption from withholding. You may claim exemption tax than necessary may be withheld, and this extra amount from withholding for 2021 if you meet both of the following will be larger the greater the difference in pay is between the conditions: you had no federal income tax liability in 2020 two jobs. and you expect to have no federal income tax liability in Multiple jobs. Complete Steps 3 through 4(b) on only 2021. You had no federal income tax liability in 2020 if (1) ! one Form W-4. Withholding will be most accurate if your total tax on line 24 on your 2020 Form 1040 or 1040-SR CAUTION you do this on the Form W-4 for the highest paying job. 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 Step 3. This step provides instructions for determining the income was below the filing threshold for your correct filing amount of the child tax credit and the credit for other status. If you claim exemption, you will have no income tax dependents that you may be able to claim when you file your withheld from your paycheck and may owe taxes and tax return. To qualify for the child tax credit, the child must penalties when you file your 2021 tax return. To claim be under age 17 as of December 31, must be your exemption from withholding, certify that you meet both of dependent who generally lives with you for more than half the conditions above by writing “Exempt” on Form W-4 in the year, and must have the required social security number. the space below Step 4(c). Then, complete Steps 1(a), 1(b), You may be able to claim a credit for other dependents for and 5. Do not complete any other steps. You will need to whom a child tax credit can’t be claimed, such as an older submit a new Form W-4 by February 15, 2022. child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Your privacy. If you prefer to limit information provided in Credit and Credit for Other Dependents. You can also Steps 2 through 4, use the online estimator, which will also include other tax credits in this step, such as education tax increase accuracy. credits and the foreign tax credit. To do so, add an estimate As an alternative to the estimator: if you have concerns of the amount for the year to your credits for dependents with Step 2(c), you may choose Step 2(b); if you have and enter the total amount in Step 3. Including these credits concerns with Step 4(a), you may enter an additional amount will increase your paycheck and reduce the amount of any you want withheld per pay period in Step 4(c). If this is the refund you may receive when you file your tax return. only job in your household, you may instead check the box Step 4 (optional). in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of Step 4(a). Enter in this step the total of your other dollars over the year). estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete When to use the estimator. Consider using the estimator at Step 4(a), you likely won’t have to make estimated tax www.irs.gov/W4App if you: payments for that income. If you prefer to pay estimated tax 1. Expect to work only part of the year; rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals. 2. Have dividend or capital gain income, or are subject to additional taxes, such as Additional Medicare Tax; Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than 3. Have self-employment income (see below); or the basic standard deduction on your 2021 tax return and 4. Prefer the most accurate withholding for multiple job want to reduce your withholding to account for these situations. deductions. This includes both itemized deductions and other Self-employment. Generally, you will owe both income and deductions such as for student loan interest and IRAs. self-employment taxes on any self-employment income you Step 4(c). Enter in this step any additional tax you want receive separate from the wages you receive as an withheld from your pay each pay period, including any employee. If you want to pay these taxes through amounts from the Multiple Jobs Worksheet, line 4. Entering an withholding from your wages, use the estimator at amount here will reduce your paycheck and will either increase www.irs.gov/W4App to figure the amount to have withheld. your refund or reduce any amount of tax that you owe. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form. 22
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 $ { } • $25,100 if you’re married filing jointly or qualifying widow(er) 2 Enter: • $18,800 if you’re head of household . . . . . . . . 2 $ • $12,550 if you’re single or married filing separately 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 You are not required to provide the information requested on a form that is on this form to carry out the Internal Revenue laws of the United States. Internal subject to the Paperwork Reduction Act unless the form displays a valid OMB Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to control number. Books or records relating to a form or its instructions must be provide this information; your employer uses it to determine your federal income retained as long as their contents may become material in the administration of tax withholding. Failure to provide a properly completed form will result in your any Internal Revenue law. Generally, tax returns and return information are being treated as a single person with no other entries on the form; providing confidential, as required by Code section 6103. fraudulent information may subject you to penalties. Routine uses of this The average time and expenses required to complete and file this form will vary information include giving it to the Department of Justice for civil and criminal depending on individual circumstances. For estimated averages, see the litigation; to cities, states, the District of Columbia, and U.S. commonwealths and instructions for your income tax return. 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 If you have suggestions for making this form simpler, we would be happy to hear may also disclose this information to other countries under a tax treaty, to federal from you. See the instructions for your income tax return. and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. 23
Form W-4 (2021) Page 4 Married Filing Jointly or Qualifying Widow(er) Higher Paying Job Lower Paying Job Annual Taxable Wage & Salary Annual Taxable $0 - $10,000 - $20,000 - $30,000 - $40,000 - $50,000 - $60,000 - $70,000 - $80,000 - $90,000 - $100,000 - $110,000 - Wage & Salary 9,999 19,999 29,999 39,999 49,999 59,999 69,999 79,999 89,999 99,999 109,999 120,000 $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 Lower Paying Job Annual Taxable Wage & Salary Annual Taxable $0 - $10,000 - $20,000 - $30,000 - $40,000 - $50,000 - $60,000 - $70,000 - $80,000 - $90,000 - $100,000 - $110,000 - Wage & Salary 9,999 19,999 29,999 39,999 49,999 59,999 69,999 79,999 89,999 99,999 109,999 120,000 $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 Lower Paying Job Annual Taxable Wage & Salary Annual Taxable $0 - $10,000 - $20,000 - $30,000 - $40,000 - $50,000 - $60,000 - $70,000 - $80,000 - $90,000 - $100,000 - $110,000 - Wage & Salary 9,999 19,999 29,999 39,999 49,999 59,999 69,999 79,999 89,999 99,999 109,999 120,000 $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 24
Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 10/31/2022 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) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number - - I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes): 1. A citizen of the United States 2. A noncitizen national of the United States (See instructions) 3. A lawful permanent resident (Alien Registration Number/USCIS Number): 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy): Some aliens may write "N/A" in the expiration date field. (See instructions) QR Code - Section 1 Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: Do Not Write In This Space An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number. 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: OR 3. Foreign Passport Number: Country of Issuance: 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 1 of 3 25
Employment Eligibility Verification USCIS Department of Homeland Security Form I-9 OMB No. 1615-0047 U.S. Citizenship and Immigration Services Expires 10/31/2022 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) First Name (Given Name) M.I. Citizenship/Immigration Status Employee Info from Section 1 List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization Document Title Document Title Document Title Issuing Authority Issuing Authority Issuing Authority Document Number Document Number Document Number Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Expiration Date (if any) (mm/dd/yyyy) Document Title QR Code - Sections 2 & 3 Issuing Authority Additional Information Do Not Write In This Space 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) Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) 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) B. Date of Rehire (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy) C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below. Document Title Document Number Expiration Date (if any) (mm/dd/yyyy) I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative Form I-9 10/21/2019 Page 2 of 3 26
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 LIST B LIST C Documents that Establish Documents that Establish Documents that Establish Both Identity and Identity Employment Authorization Employment Authorization OR AND 1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number State or outlying possession of the card, unless the card includes one of 2. Permanent Resident Card or Alien United States provided it contains a the following restrictions: Registration Receipt Card (Form I-551) photograph or information such as (1) NOT VALID FOR EMPLOYMENT name, date of birth, gender, height, eye 3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH temporary I-551 stamp or temporary INS AUTHORIZATION I-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH readable immigrant visa government agencies or entities, DHS AUTHORIZATION provided it contains a photograph or 4. Employment Authorization Document information such as name, date of birth, 2. Certification of report of birth issued that contains a photograph (Form gender, height, eye color, and address by the Department of State (Forms I-766) DS-1350, FS-545, FS-240) 3. School ID card with a photograph 5. For a nonimmigrant alien authorized 3. Original or certified copy of birth to work for a specific employer 4. Voter's registration card certificate issued by a State, because of his or her status: county, municipal authority, or 5. U.S. Military card or draft record territory of the United States a. Foreign passport; and 6. Military dependent's ID card bearing an official seal b. Form I-94 or Form I-94A that has the following: 7. U.S. Coast Guard Merchant Mariner 4. Native American tribal document (1) The same name as the passport; Card 5. U.S. Citizen ID Card (Form I-197) and 8. Native American tribal document (2) An endorsement of the alien's 6. Identification Card for Use of nonimmigrant status as long as 9. Driver's license issued by a Canadian Resident Citizen in the United that period of endorsement has government authority States (Form I-179) not yet expired and the proposed employment is not in For persons under age 18 who are 7. Employment authorization conflict with any restrictions or unable to present a document document issued by the limitations identified on the form. Department of Homeland Security listed above: 6. Passport from the Federated States 10. School record or report card of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with 11. Clinic, doctor, or hospital record Form I-94 or Form I-94A indicating nonimmigrant admission under the 12. Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI Examples of many of these documents appear in the Handbook for Employers (M-274). Refer to the instructions for more information about acceptable receipts. Form I-9 10/21/2019 Page 3 of 3 27
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