Please provide the full legal name of the employee (as it appears on your income tax return or social security card)
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- Jack Lambert
- 5 years ago
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1 EMPLOYEE WORKSHEET EMPLOYEE CONTACT INFORMATION: Name of Employer: Please provide the full legal name of the employee (as it appears on your income tax return or social security card) Mr. First Name M.I. Last Name Social Security Number Mrs. Ms. Home Address Apt. City State Zip Code Home Phone Cell Phone Address Male Female Date of Birth Rate of Pay Access paystubs online - Paystub notifications sent directly to you via (with online access to all prior history). EMPLOYEE BANK ACCOUNT INFORMATION: In order to set up payroll direct deposit, we need to establish an electronic link between the employer's bank account and the employee's bank account. Bank Routing Number (9 Digits): Bank Account Number: IMPORTATNT NOTE: In order to validate this account, we will be required to run a test transaction through this account that will need to be validated. We will discuss the details and timing of this when we have completed the electronic enrollment component of the employer set-up process. Check one box: Checking Account Savings Account Please include a voided check with paperwork submission. ELECTRONIC FUNDS AUTHORIZATION: I hereby authorize Redlig Financial Services Inc. to initiate electronic funds transfer and deposit the net pay into the bank account number provided above. X Authorized Signature Date Printed Name REDLIG FINANCIAL SERVICES INC. 40 PRESCOTT AVENUE, SUITE 1L, WHITE PLAINS, NY WESTCHESTER: (914) NYC: (646) LONG ISLAND: (516) FAX: (516)
2 Ú± ³ Éóì øîðïè Ú« ¼»ª» ± ³»² ò Ú±»» ²º± ³ ±² ¾±«² º« ¼»ª» ± ³»²»»¼ ± Ú± ³ Éóìô «½»¹ ±²»² ½»¼ º» «¾»¼ô ¹± ± ò ò¹±ªñú± ³Éìò Ы±»ò ݱ³»» Ú± ³ Éóì ± ±³ ±» ½ ² ± ¼» ½±»½ º»¼» ²½±³» º ±³ ±«ò ݱ² ¼» ½±³» ²¹ ²» Ú± ³ Éóì» ½» ²¼»² ± ±² ± º ² ²½ «±² ½ ²¹» ò Û»³ ±² º ±³ ± ¼ ²¹ò DZ«³ ½ ³»»³ ±² º ±³ ± ¼ ²¹ º± îðïè º ¾± ±º» º± ± ²¹ ò Ú± îðïé ±«¼ ¹ ±»º«²¼ ±º º»¼» ²½±³»» ¼ ¾»½ ±«¼ ²± ¾ ô ²¼ Ú± îðïè ±»½»º«²¼ ±º º»¼» ²½±³»» ¼ ¾»½ ±»½ ± ª» ²± ¾ ò º ±»»³ ô ½±³»» ±² ²» ïô îô íô ìô ²¼ é ²¼ ¹²» º± ³ ± ª ¼» ò DZ»³ ±² º± îðïè»» Ú»¾ «ïëô îðïçò Í»» Ы¾ò ëðëô Ì É ± ¼ ²¹ ²¼ Û ³»¼ Ì ô ±» ² ³±» ¾±» ±««º º±»»³ ±² º ±³ ± ¼ ²¹ò Ù»²» ² «½ ±² º ±²»»³ ô º± ±»» ±º»» ² «½ ±² ± ¼»» ³ ²»» ²«³¾» ±º ± ¼ ²¹ ± ²½» ±«±«¼ ½ ³ º± ± ¼ ²¹ º± îðïè ²¼ ² ¼¼ ±² ³±«² ±º ± ª»» ¼ò Ú±»¹«¹» ô ± ¼ ²¹ ³«¾» ¾»¼ ±² ± ²½» ±«½ ³»¼ ²¼ ³ ²± ¾» º ³±«² ±» ½»² ¹» ±º ¹» ò DZ«½ ² ± » ½ ½«± ò ò¹±ªñéìß ± ¼»» ³ ²» ±«± ¼ ²¹ ³±» ½½ ò ݱ² ¼» Ú± ³ Ü» ³»² ±º» Ì» «²» ² 못² Í» ª ½» «²¹ ½ ½«± º ±«ª» ³±» ½±³ ½»¼ «±²ô «½ º ±«ª» ± µ ²¹ ±ô ³±» ² ±²» ±¾ô ± ¹» ³±«² ±º ²±² ¹» ²½±³» ±«¼» ±º ±«±¾ò ߺ» ±«Ú± ³ Éóì µ»»ºº»½ ô ±«½ ² ± ½ ½«± ±»» ±» ³±«² ±º ± ª ²¹» ¼ ½±³» ± ±«±»½»¼ ± º± îðïèò º ±«» ½ ½«± ô ±«¼±² ²»»¼ ± ½±³»» ² ±º» ± µ»» º± Ú± ³ Éóìò Ò±» º ±«ª» ±± ³«½» ¼ô ±½» ª»»º«²¼»² ±«º» ± «²ò º ±«ª» ±±»» ¼ô ±«±»»² ±«º» ± «²ô ²¼ ±«³ ¹ ±»»² ò Ú» ³ ±¾ ± ± µ ²¹ ± ò º ±«ª» ³±» ² ±²» ±¾ ³»ô ± º ± ³»¼ ²¼ ±«± ± ± µ ²¹ô» ¼ ±º» ² «½ ±² ²½ «¼ ²¹» ² «½ ±² º±» Ì ±óû ²» ñó Ö±¾ ɱ µ»» ¾»º±» ¾»¹ ²² ²¹ò Ò±² ¹» ²½±³»ò º ±«ª» ¹» ³±«² ±º ²±² ¹» ²½±³»ô «½ ²»» ± ¼ ª ¼»²¼ ô ½±² ¼» ³ µ ²¹» ³»¼ ³»² «²¹ Ú± ³ ïðìðó ÛÍô Û ³»¼ Ì º± ²¼ ª ¼«ò Ñ»»ô ±«³ ¹ ±» ¼¼ ±² ò Ñ ô ±«½ ² » Ü»¼«½ ±² ô ß¼ «³»² ô ²¼ Ñ» ²½±³» ɱ µ»» ±² ¹» í ±» ½ ½«± ò ò¹±ªñ Éìß ± ³ µ» ±«ª»»²±«¹» ¼ º ±³ ±«½»½µò º ±«ª»»² ±² ± ²²«²½±³»ô»» Ы¾ò ëðë ± » ½ ½«± ò ò¹±ªñéìß ± º ²¼ ±«º ±«±«¼ ¼ «±«± ¼ ²¹ ±² Ú± ³ Éóì ± ÉóìÐò Ò±²» ¼»²»²ò º ± ²±²» ¼»²»²ô»» Ò± ½» ïíçîô ͳ»² Ú± ³ Éóì ² «½ ±² º± Ò±²» ¼»² ß»² ô ¾»º±» ½±³» ²¹ º± ³ò Í»»»» ²¼ ¹ ª» Ú± ³ Éóì ± ±³ ±» ò Õ»»» ± µ»» ø º± ±½± ¼ ò Û³ ±»» É ± ¼ ²¹ ß ± ²½» Ý» º ½» É»» ±»²»¼ ± ½ ³ ½» ² ²«³¾» ±º ± ²½» ±»»³ ±² º ±³ ± ¼ ²¹ «¾»½ ±»ª» ¾» ÎÍò DZ³ ±» ³ ¾»» ¼ ±»²¼ ½± ±º º± ³ ±» ÎÍò ï DZ«º ² ³» ²¼ ³ ¼¼» ² Ô ² ³» Í»½ º ½ ² «½ ±² л ±² ß ± ²½» ɱ µ»» ݱ³»» ± µ»» ±² ¹» í º ± ¼»» ³ ²»» ²«³¾» ±º ± ¼ ²¹ ± ²½» ± ½ ³ò Ô ²» Ýò Ø» ¼ ±º ± ± ¼»» ²±»æ Ù»²» ô ±«½ ² ½ ³» ¼ ±º ± ± ¼ º ²¹ «±² ± «² ±² º ± «²³»¼ ²¼ ³±» ² ëðû ±º» ½± ±º µ»» ²¹ «±³» º± ± º ²¼ «º ²¹ ²¼ ª ¼«ò Í»» Ы¾ò ëðï º± ³±» ²º± ³ ±² ¾±«º ²¹ «ò Ô ²» Ûò Ý ¼ ½»¼ ò É»² ±«º» ± «²ô ±«³ ¹ ¾»» ¹ ¾» ± ½ ³ ½»¼ º±» ½ ±º ±««º ²¹ ½ ¼»²ò ̱ «º ô» ½ ¼ ³«¾» «²¼» ¹» ïé ±º Ü»½»³¾» íï ²¼ ³«¾» ±«¼»»²¼»² ± ª» ±«º± ³±» ² º»» ò ̱» ² ³±» ¾±«½»¼ ô»» Ы¾ò çéîô Ý ¼ Ì Ý»¼ ò ̱»¼«½»»» ¼ º ±³ ±«¾ µ ²¹ ½»¼ ² ± ½½±«² ô º± ±» ² «½ ±² ±² ²» Û ±º» ± µ»» ò Ѳ» ± µ»» ±«¾» µ»¼ ¾±«±«± ²½±³»ò Ú± «±»ô ± ²½±³» ²½ «¼» ±º ±«¹» ²¼ ±» ²½±³»ô ²½ «¼ ²¹ ²½±³»» ²»¼ ¾ ±ô ¼«²¹»» ò Ô ²» Úò Ý»¼ º± ±» ¼»»²¼»² ò É»² ±«º» ± «²ô ±«³ ¹ ¾»» ¹ ¾» ± ½ ³ ½»¼ º±» ½ ±º ±«¼»»²¼»² ¼±² «º º±» ½ ¼ ½»¼ ô «½ ² ¼»»²¼»² ½ ¼»² ¹» ïé ²¼ ± ¼» ò ̱» ² ³±» ¾±«½»¼ ô»» Ы¾ò ëðëò ̱»¼«½»»» ¼ º ±³ ±«¾ µ ²¹ ½»¼ ² ± ½½±«² ô º± ±» ² «½ ±² ±² ²» Ú ±º» ± µ»» ò Ѳ» ± µ»» ô ±«¾» µ»¼ ¾±«±«± ²½±³»ò Ú± «±»ô ± ²½±³» ²½ «¼» ±º î ÑÓÞ Ò±ò ïëìëóððéì DZ«±½»½«²«³¾» ر³» ¼¼» ø²«³¾» ²¼»» ± «± Ý ± ± ²ô»ô ²¼ Æ Ð ½±¼» í Í ²¹» Ó»¼ Ó»¼ô ¾«± ¼ ¹» Í ²¹»»ò Ò±»æ º ³»¼ º ²¹»» ô ½»½µ Ó»¼ô ¾«± ¼ ¹» Í ²¹»»ò ì º ±«² ³» ¼ ºº» º ±³ ± ² ±² ±«±½»½«½ ¼ô ½»½µ»»ò DZ«³«½ èððóééîóïîïí º±» ½»³»² ½ ¼ò ë ̱ ²«³¾» ±º ± ²½» ± ½ ³ ²¹ øº ±³» ½ ¾» ± µ»» ±²» º± ± ²¹ ¹» ò ò ò ë ê ß¼¼ ±² ³±«² ô º ² ô ±«²» ¼ º ±³» ½ ½»½µ ò ò ò ò ò ò ò ò ò ò ò ò ò ò ê ü é ½ ³»»³ ±² º ±³ ± ¼ ²¹ º± îðïèô ²¼ ½» º ³»» ¾± ±º» º± ± ²¹ ½±²¼ ±² º±»»³ ±²ò Ô» ¼ ¹ ±»º«²¼ ±º º»¼» ²½±³»» ¼ ¾»½ ¼ ²± ¾ ô ²¼ Ì»»»½»º«²¼ ±º º»¼» ²½±³»» ¼ ¾»½ »»½ ± ª» ²± ¾ ò º ±«³»» ¾± ½±²¼ ±² ô» Û»³»» ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò é ˲¼»»²» ±º» «ô ¼»½» ª»» ³ ²»¼ ½» º ½» ²¼ô ±» ¾» ±º ³ µ²±»¼¹» ²¼ ¾»»ºô ô ½±»½ ô ²¼ ½±³»»ò Û³ ±»» ¹² øì º± ³ ²± ª ¼ «²» ±«¹² ò è Û³ ±» ² ³» ²¼ ¼¼» øû³ ±» æ ݱ³»» ¾±» è ²¼ ï𠺻²¼ ²¹ ± ÎÍ ²¼ ½±³»» ¾±» èô çô ²¼ ï𠺻²¼ ²¹ ± Í» Ü»½ ± ±º Ò» Ø» ò ç Ú ¼» ±º»³ ± ³»² Ü» ïð Û³ ±» ¼»² º ½ ±² ²«³¾» øû Ò Ú± Ð ª ½ ß½ ²¼ л ± µ λ¼«½ ±² ß½ Ò± ½»ô»» ¹» ìò Ý ò Ò±ò ïðîîðï Ú± ³ Éóì øîðïè
3 Ú± ³ Éóì øîðïè л ±² ß ± ²½» ɱ µ»» øõ»» º± ±½± ¼ ò ß Û²» ï º± ± º ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ß Þ Û²» ï º ±«º» ³»¼ º ²¹ ± ² ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò Þ Ý Û²» ï º ±«º»» ¼ ±º ± ± ¼ ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò Ý Ü Û²» ï ºæ DZ ²¹»ô ± ³»¼ º ²¹»» ô ²¼ ª» ±² ±²» ±¾å ± DZ ³»¼ º ²¹ ± ² ô ª» ±² ±²» ±¾ô ²¼ ±«± ¼±» ² ± µå ± DZ«¹» º ±³»½±²¼ ±¾ ± ±«± ¹» ø±» ± ±º ¾±» üïôëðð ±» ò Ü Û Ý ¼ ½»¼ ò Í»» Ы¾ò çéîô Ý ¼ Ì Ý»¼ ô º± ³±» ²º± ³ ±²ò º ±«± ²½±³» ¾»» ² üêçôèðï øüïðïôìðï º ³»¼ º ²¹ ± ² ô»²» ì º±» ½» ¹ ¾» ½ ¼ò º ±«± ²½±³» ¾» º ±³ üêçôèðï ± üïéëôëëð øüïðïôìðï ± üííçôððð º ³»¼ º ²¹ ± ² ô»²» î º±» ½» ¹ ¾» ½ ¼ò Ú º ±«± ²½±³» ¾» º ±³ üïéëôëëï ± üîððôððð øüííçôððï ± üìððôððð º ³»¼ º ²¹ ± ² ô»²» ï º±» ½» ¹ ¾» ½ ¼ò º ±«± ²½±³» ¾» ¹» ² üîððôððð øüìððôððð º ³»¼ º ²¹ ± ² ô»²» óðó ò ò ò ò ò ò ò Û Ý»¼ º± ±» ¼»»²¼»² ò º ±«± ²½±³» ¾»» ² üêçôèðï øüïðïôìðï º ³»¼ º ²¹ ± ² ô»²» ï º±» ½» ¹ ¾» ¼»»²¼»² ò º ±«± ²½±³» ¾» º ±³ üêçôèðï ± üïéëôëëð øüïðïôìðï ± üííçôððð º ³»¼ º ²¹ ± ² ô»²» ï º±»ª» ± ¼»»²¼»² øº±» ³»ô óðó º± ±²» ¼»»²¼»² ô ï º ±«ª» ± ±»» ¼»»²¼»² ô ²¼ î º ±«ª» º±«¼»»²¼»² ò º ±«± ²½±³» ¾» ¹» ² üïéëôëëð øüííçôððð º ³»¼ º ²¹ ± ² ô»²» óðó ò ò ò ò ò ò ò Ú Ù Ñ» ½»¼ ò º ±«ª» ±» ½»¼ ô»» ɱ µ»» ïóê ±º Ы¾ò ëðë ²¼»²»» ³±«² º ±³ ± µ»»»» ò ò Ù Ø ß¼¼ ²» ß ±«¹ Ù ²¼»²»» ±»» ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò Ø Ð ¹» í Ú± ½½«½ ô ½±³»» ± µ»» ò º ±«² ±»³» ± ½ ³ ¼ «³»² ± ²½±³» ²¼ ² ±»¼«½» ±«± ¼ ²¹ô ± º ±«ª» ¹» ³±«² ±º ²±² ¹» ²½±³» ²¼ ² ± ²½»» ±«± ¼ ²¹ô»»» Ü»¼«½ ±² ô ß¼ «³»² ô ²¼ ß¼¼ ±² ²½±³» ɱ µ»» ¾» ± ò º ±«ª» ³±» ² ±²» ±¾ ³» ±» ³»¼ º ²¹ ± ² ²¼ ±«²¼ ±«± ¾± ± µô ²¼» ½±³¾ ²»¼» ² ²¹ º ±³ ±¾» ½»»¼ üëîôððð øüîìôððð º ³»¼ º ²¹ ± ² ô»»» Ì ±óû ²» ñó Ö±¾ ɱ µ»» ±² ¹» ì ± ª± ¼ ª ²¹ ±±»» ¼ò º ²»» ±º» ¾±ª» «±²» ô ±»» ²¼»²»» ²«³¾» º ±³ ²» Ø ±² ²» ë ±º Ú± ³ Éóì ¾±ª»ò Ü»¼«½ ±² ô ß¼ «³»² ô ²¼ ß¼¼ ±² ²½±³» ɱ µ»» Ò±»æ Ë» ± µ»» ±² º ±«² ±»³» ¼»¼«½ ±² ô ½ ³ ½» ² ¼ «³»² ± ²½±³»ô ± ª» ¹» ³±«² ±º ²±² ¹» ²½±³»ò ï Û²» ²» ³» ±º ±«îðï軳»¼ ¼»¼«½ ±² ò Ì»» ²½ «¼» «º ²¹ ±³» ³± ¹ ¹» ²»» ô ½ ¾» ½±² ¾«±² ô» ²¼ ±½» ø«± üïðôððð ô ²¼ ³»¼ ½»»²» ²» ½» ±º éòëû ±º ±«²½±³»ò Í»» Ы¾ò ëðë º± ¼» ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ï ü î Û²» æ üîìôððð º ± ³»¼ º ²¹ ± ² ± «º ²¹ ¼± ø» üïèôððð º ±» ¼ ±º ± ± ¼ üïîôððð º ± ²¹» ± ³»¼ º ²¹»» ò ò ò ò ò ò ò ò ò ò ò î ü í Í«¾ ½ ²» î º ±³ ²» ïò º» ± ±» ô»²» óðó ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò í ü ì Û²» ²» ³» ±º ±«îðïè ¼ «³»² ± ²½±³» ²¼ ² ¼¼ ±² ²¼ ¼ ¼»¼«½ ±² º± ¹» ± ¾ ²¼²» ø»» Ы¾ò ëðë º± ²º± ³ ±² ¾±»»³ ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ì ü ë ß¼¼ ²» í ²¼ ì ²¼»²»» ± ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ë ü ê Û²» ²» ³» ±º ±«îðïè ²±² ¹» ²½±³» ø «½ ¼ ª ¼»²¼ ± ²»» ò ò ò ò ò ò ò ò ò ê ü é Í«¾ ½ ²» ê º ±³ ²» ëò º» ±ô»²» óðóò º» ²» ±ô»²»» ³±«² ²»²»» ò ò ò é ü è Ü ª ¼»» ³±«² ±² ²» é ¾ üìôïëð ²¼»²»»» »ò º ²»¹ ª» ³±«² ô»²» ²»²»» ò Ü ± ² º ½ ±² ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò è ç Û²»» ²«³¾» º ±³» л ±² ß ± ²½» ɱ µ»» ô ²» Ø ¾±ª» ò ò ò ò ò ò ò ò ò ò ç ïð ß¼¼ ²» è ²¼ ç ²¼»²»» ±»»ò º» ± ±» ô»²» óðóò º ±«² ± » Ì ±óû ²» ñ Ó Ö±¾ ɱ µ»» ô ±»²» ± ±² ²» ïô ¹» ìò Ñ»»ô ±»» ²¼»²» ± ±² Ú± ³ Éóìô ²» ëô ¹» ï ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ïð
4 Ú± ³ Éóì øîðïè Ì ±óû ²» ñó Ö±¾ ɱ µ»» Ò±»æ Ë» ± µ»» ±² º» ² «½ ±² «²¼» ²» Ø º ±³» л ±² ß ± ²½» ɱ µ»» ¼»½ ±»ò ï Û²»» ²«³¾» º ±³» л ±² ß ± ²½» ɱ µ»» ô ²» Øô ¹» í ø± ô º ±«¼» Ü»¼«½ ±² ô ß¼ «³»² ô ²¼ ß¼¼ ±² ²½±³» ɱ µ»» ±² ¹» íô» ²«³¾» º ±³ ²» ï𠱺 ± µ»» ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ï î Ú ²¼» ²«³¾» ² Ì ¾» ï ¾» ±» ±» ÔÑÉÛÍÌ ²¹ ±¾ ²¼»²»»»ò ر»ª» ô º ± ³»¼ º ²¹ ± ² ²¼ ¹» º ±³» ¹» üéëôððð ±» ²¼» ½±³¾ ²»¼ ¹» º± ±«²¼ ±«±» üïðéôððð ±» ô ¼±²»²» ³±» ² í ò ò ò ò ò ò ò ò ò ò ò ò ò î í º ²» ï ³±» ² ±» «± ²» îô «¾ ½ ²» î º ±³ ²» ïò Û²»»» » ø º» ±ô»²» óðó ²¼ ±² Ú± ³ Éóìô ²» ëô ¹» ïò ܱ ²± »» ±º ± µ»» ò ò ò ò ò ò ò ò ò ò ò ò í Ò±»æ º ²» ï» ² ²» îô»²» óðó ±² Ú± ³ Éóìô ²» ëô ¹» ïò ݱ³»» ²» ì ±«¹ ç ¾» ± ± º ¹» ¼¼ ±² ± ¼ ²¹ ³±«² ²»½» ± ª± ¼» ó»²¼ ¾ ò ì Û²»» ²«³¾» º ±³ ²» î ±º ± µ»» ò ò ò ò ò ò ò ò ò ò ò ì ë Û²»» ²«³¾» º ±³ ²» ï ±º ± µ»» ò ò ò ò ò ò ò ò ò ò ò ë ê Í«¾ ½ ²» ë º ±³ ²» ì ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ê é Ú ²¼» ³±«² ² Ì ¾» î ¾» ±» ±» Ø ÙØÛÍÌ ²¹ ±¾ ²¼»²»»» ò ò ò ò ò é ü è Ó«²» é ¾ ²» ê ²¼»²»»» »ò Ì» ¼¼ ±² ²²«± ¼ ²¹ ²»»¼»¼ ò ò ò è ü ç Ü ª ¼» ²» è ¾» ²«³¾» ±º» ±¼»³ ² ²¹ ² îðïèò Ú±» ³»ô ¼ ª ¼» ¾ ïè º ± ¼»ª» î»»µ ²¼ ±«½±³»» º± ³ ±² ¼» ²» ß»²»»» ïè» ±¼»³ ² ²¹ ² îðïèò Û²»»» » ²¼ ±² Ú± ³ Éóìô ²» êô ¹» ïò Ì» ¼¼ ±² ³±«² ± ¾»» ¼ º ±³» ½ ½»½µ ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ò ç ü Ì ¾» ï Ì ¾» î Ó»¼ Ú ²¹ Ö± ² ß Ñ» Ó»¼ Ú ²¹ Ö± ² ß Ñ» º ¹» º ±³ ÔÑÉÛÍÌ ²» î ¾±ª» üð ó üëôððð ð ëôððï ó çôëðð ï çôëðï ó ïçôððð î ïçôððï ó îêôëðð í îêôëðï ó íéôððð ì íéôððï ó ìíôëðð ë ìíôëðï ó ëëôððð ê ëëôððï ó êðôððð é êðôððï ó éðôððð è éðôððï ó éëôððð ç éëôððï ó èëôððð ïð èëôððï ó çëôððð ïï çëôððï ó ïíðôððð ïî ïíðôððï ó ïëðôððð ïí ïëðôððï ó ïêðôððð ïì ïêðôððï ó ïéðôððð ïë ïéðôððï ó ïèðôððð ïê ïèðôððï ó ïçðôððð ïé ïçðôððï ó îððôððð ïè îððôððï ²¼ ±ª» ïç º ¹» º ±³ ÔÑÉÛÍÌ ²» î ¾±ª» üð ó üéôððð ð éôððï ó ïîôëðð ï ïîôëðï ó îìôëðð î îìôëðï ó íïôëðð í íïôëðï ó íçôððð ì íçôððï ó ëëôððð ë ëëôððï ó éðôððð ê éðôððï ó èëôððð é èëôððï ó çðôððð è çðôððï ó ïððôððð ç ïððôððï ó ïðëôððð ïð ïðëôððï ó ïïëôððð ïï ïïëôððï ó ïîðôððð ïî ïîðôððï ó ïíðôððð ïí ïíðôððï ó ïìëôððð ïì ïìëôððï ó ïëëôððð ïë ïëëôððï ó ïèëôððð ïê ïèëôððï ²¼ ±ª» ïé º ¹» º ±³ Ø ÙØÛÍÌ ²» é ¾±ª» üð ó üîìôíéë üìîð îìôíéê ó èîôéîë ëðð èîôéîê ó ïéðôíîë çïð ïéðôíîê ó íîðôíîë ïôððð íîðôíîê ó ìðëôíîë ïôííð ìðëôíîê ó êðëôíîë ïôìëð êðëôíîê ²¼ ±ª» ïôëìð º ¹» º ±³ Ø ÙØÛÍÌ ²» é ¾±ª» üð ó üéôððð üìîð éôððï ó íêôïéë ëðð íêôïéê ó éçôçéë çïð éçôçéê ó ïëìôçéë ïôððð ïëìôçéê ó ïçéôìéë ïôííð ïçéôìéê ó ìçéôìéë ïôìëð ìçéôìéê ²¼ ±ª» ïôëìð Ð ¹» ì Ð ª ½ ß½ ²¼ л ± µ λ¼«½ ±² ß½ Ò± ½»ò É» µ º±» ²º± ³ ±² ±² º± ³ ± ½ ± ²» ² 못² ±º» ˲»¼ Í» ò ²» ² 못² ݱ¼»»½ ±² íìðîøº øî ²¼ êïðç ²¼»»¹«±²» ±«± ±ª ¼» ²º± ³ ±²å ±³ ±» ± ¼»» ³ ²» ±«º»¼» ²½±³» ± ¼ ²¹ò Ú ± ±ª ¼» ±» ½±³»»¼ º± ³» «² ±«¾» ²¹»»¼ ²¹»» ±² ± ½ ³ ²± ± ¼ ²¹ ± ²½» å ±ª ¼ ²¹ º «¼² ²º± ³ ±² ³ «¾»½ ±«±»²» ò α«²» ±º ²º± ³ ±² ²½ «¼» ¹ ª ²¹ ±» Ü» ³»² ±º Ö«½» º± ½ ª ²¼ ½ ³ ² ¹ ±²å ± ½» ô» ô» Ü ½ ±º ݱ «³¾ ô ²¼ ËòÍò ½±³³±²» ²¼ ±» ±² º± ² ¼³ ²» ²¹» å ²¼ ±» Ü» ³»² ±º Ø» ²¼ Ø«³ ² Í» ª ½» º± ²» Ò ±² Ü»½ ± ±º Ò» Ø» ò É» ³ ± ¼ ½ ±» ²º± ³ ±² ± ±» ½±«²» «²¼»» ô ± º»¼» ²¼» ¹»²½» ±»²º± ½» º»¼» ²±² ½ ³ ² ô ± ± º»¼»»²º± ½»³»² ²¼ ²» ¹»²½» ¹»²½» ± ½±³¾» ± ³ò DZ²» ¼ ± ±ª ¼»» ²º± ³ ±²» »¼ ±² º± ³ «¾»½ ±» л ± µ λ¼«½ ±² ß½ «²»» º± ³ ¼ ª ¼ ÑÓÞ ½±² ± ²«³¾» ò Þ±±µ ±»½± ¼» ²¹ ± º± ³ ± ² «½ ±² ³«¾»» ²»¼ ±²¹» ½±²»² ³ ¾»½±³» ³» ²» ¼³ ² ±² ±º ² ²» ² 못² ò Ù»²» ô» «² ²¼» «² ²º± ³ ±²» ½±²º ¼»² ô» ¼ ¾ ݱ¼»»½ ±² êïðíò Ì» ª» ¹» ³» ²¼»»²»» ¼ ± ½±³»» ²¼ º» º± ³ ª ¼»»²¼ ²¹ ±² ²¼ ª ¼«½ ½«³ ²½» ò Ú±» ³»¼ ª» ¹» ô»»» ² «½ ±² º± ±«²½±³»» «²ò º ±«ª» «¹¹» ±² º± ³ µ ²¹ º± ³ ³» ô» ±«¼ ¾» ±» º ±³ ±«ò Í»»» ² «½ ±² º± ±«²½±³»» «²ò
5 Employment Eligibility Verification Department of Homeland Security U.S. Citizenship and Immigration Services USCIS Form I-9 OMB No Expires 03/31/2016 START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire 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 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 - - Address 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): A citizen of the United States A noncitizen national of the United States (See instructions) A lawful permanent resident (Alien Registration Number/USCIS Number): An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) (See instructions). Some aliens may write "N/A" in this field. For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number: 1. Alien Registration Number/USCIS Number: OR 2. Form I-94 Admission Number: 3-D Barcode Do Not Write in This Space If you obtained your admission number from CBP in connection with your arrival in the United States, include the following: Foreign Passport Number: Country of Issuance: Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) Signature of Employee: Date (mm/dd/yyyy): Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct. Signature of Preparer or Translator: 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 03/08/13 N Page 7 of 9
6 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 examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.) Employee Last Name, First Name and Middle Initial from Section 1: List A OR List B AND List C Identity and Employment Authorization Identity Employment Authorization 3-D Barcode Do Not Write in This Space 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 Date (mm/dd/yyyy) Title of Employer or Authorized Representative Last Name (Family Name) First Name (Given Name) Employer's Business or Organization Name Employer's Business or Organization Address (Street Number and Name) City or Town State Zip Code Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.) A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial B. Date of Rehire (if applicable) (mm/dd/yyyy): C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee presented that establishes current employment authorization in the space provided below. I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative: Date (mm/dd/yyyy): Print Name of Employer or Authorized Representative: Form I-9 03/08/13 N Page 8 of 9
7 LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED LIST A LIST B LIST C Documents that Establish Both Identity and Employment Authorization Employees may present one selection from List A or a combination of one selection from List B and one selection from List C. OR Documents that Establish Identity AND Documents that Establish Employment Authorization 1. U.S. Passport or U.S. Passport Card 2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) 3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machinereadable immigrant visa 4. Employment Authorization Document that contains a photograph (Form I-766) 5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status: a. Foreign passport; and b. Form I-94 or Form I-94A that has the following: (1) The same name as the passport; and (2) An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form. 6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI 1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address 3. School ID card with a photograph 4. Voter's registration card 5. U.S. Military card or draft record 6. Military dependent's ID card 7. U.S. Coast Guard Merchant Mariner Card 8. Native American tribal document 9. Driver's license issued by a Canadian government authority For persons under age 18 who are unable to present a document listed above: 10. School record or report card 11. Clinic, doctor, or hospital record 12. Day-care or nursery school record 1. A Social Security Account Number card, unless the card includes one of the following restrictions: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION 2. Certification of Birth Abroad issued by the Department of State (Form FS-545) 3. Certification of Report of Birth issued by the Department of State (Form DS-1350) 4. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal 5. Native American tribal document 6. U.S. Citizen ID Card (Form I-197) 7. Identification Card for Use of Resident Citizen in the United States (Form I-179) 8. Employment authorization document issued by the Department of Homeland Security Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274). Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts. Form I-9 03/08/13 N Page 9 of 9
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