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.
3General 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 _____________________________
4Athens 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: _______________________
5Athens 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:
6Athens 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:
7Athens 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:
8Athens 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:
9Athens 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.
1011. 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.
1124. 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:
12Athens 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:
13Athens 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.
145. 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.
159. 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:
16YMCA & 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
18III. 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.
19Criminal 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
20Form 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)
21Form 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.
22Form 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.
23Form 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
24Employment 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
25Employment 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
26LISTS 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
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