* Please complete all questions on this application as thoroughly as possible

Personal Data

   Yes     No If Yes, please provide any past name(s):
* This field is Required

 Yes    No
* This field is Required

 Yes    No
* This field is Required

 Yes    No
* This field is Required
 Yes    No
* This field is Required

Employment

(List most recent employer first. Complete this section fully including all compensation information.)




 Yes    No

 Yes    No

Education

Yes No

Yes No

Emergency Contact Information

Applicant Waiver

hereby certify that I am at least 18 years of age and the information in this document is correct to the best of my knowledge and understand that falsification of this information is grounds for refusal to hire or, if hired, dismissal.

I hereby authorize any of the persons or organizations listed in my application to give all information concerning my previous employment, education, or any other information they might have,personal or otherwise, with regard to any of the subjects covered by this application, and release all such parties from all liability that may result from furnishing such information to you. I authorize you to request and receive such information.

In consideration for my employment and my being considered for employment by your company’s sole option and without any prior notice. In addition, I acknowledge that my employment may be terminated, and any offer of employment, if such is made, may be withdrawn, with or without prior notice, at any time, at the option of either the company or myself.

I understand that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to ensure or make some other personnel move, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or to make any agreement, that is contrary to the foregoing.

I hereby acknowledge that I have been advised that this application will remain active for no more than 90 days from the date is was signed

Release of Personal Information

I authorize CountryWide Staffing Solutions Group to collect, use, store, transfer, and purge the personal information I have provided exclusively for employment-related purposes.(Note: CountryWide Staffing Solutions Group’s Privacy Statement is available upon request.

Non-Disclosure and Assignment of Intellectual Property RightsAgreement

Without CountryWide Staffing Solutions Group’s prior written approval, I will not publish, use,copy, retain possession of, or disclose any proprietary or confidential information of CountryWide Staffing Solutions Group or any CountryWide Staffing Solutions Group customer. In addition, I understand that the ownership of any work I create will belong to CountryWide Staffing Solutions Group, and I hereby assign any intellectual property rights that arise from my work to CountryWide Staffing Solutions Group.

Limitations on Actions

I agree to bring any claims that I may have against the Company within 300 days of the day that I knew, or should have known, of the facts giving rise to the cause of action and waive any longer,but not shorter, statutory or other limitations periods. This includes, but is not limited to, the initial filing of a charge with the Equal Employment Opportunity Commission and/or state equivalent civil rights agency. However, I understand that I will thereafter have the right to pursue any federal claim in the manner prescribed in any right to sue letter that is issued by an agency.

Choice of Law and Jurisdiction and Forum

I understand any disputes related to this Application, Agreement, and/or my employment relationship with CountryWide Staffing Solutions Group shall be governed by the laws of the State of Tennessee (the location of CountryWide Staffing Solutions Group’s head quarters), regardless of conflicts of law principles. Any action arising out of this Application, Agreement, or relationship between me and CountryWide Staffing Solutions Group established herein shall be brought only in the Stateof Tennessee Courts of appropriate venue, or the United States District Court sitting in Tennessee,and I consent to and submit myself to the jurisdiction of the Courts.

Release for Background Screening (Not Applicable in Arizona)

I authorize CountryWide Staffing Solutions Group to verify any information that I provide in connection with my employment. I release CountryWide Staffing Solutions Group, its customers,its authorized representatives, and the consumer reporting agency from all liability resulting from the use of background information that can be lawfully obtained about me for employment purposes.

EEO: EEO-1 Voluntary Self Identification Form
CountryWide Staffing Solutions Group is an Equal Opportunity Employer

Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment. CountryWide Staffing Solutions Group is an Equal Opportunity Employer. As required by law, we must record certain information to be made a part of our EEO -1 Reporting.

Applicants for employment are also invited to participate in the Affirmative Action Program by reporting their status as disabled, disabled veteran, veteran of the Vietnam era or other minority. In extending this invitation you are also advised that: (a) workers (applicants) are under no obligation to respond, but may do so in the future if they choose; (b) responses will remain confidential within the Human Resources Department; and (c) responses will be used only for the necessary information to include in our EEO -1 reporting as applicable. We are a company that values diversity. We actively encourage women and minorities to apply.

Refusal to provide this information will have no bearing on your application and will not subject you to any adverse treatment. This information will be kept separate from all other personnel records only accessed by Human Resources Department. Please return completed forms to the Human Resources Department.

GENDER: (Please check one of the optionsbelow)

 Male    Female


RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.)

    Hispanic or Latino
    White (Not Hispanic or Latino
    Black or African American (Not Hispanic or Latino
    Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino

    Asian (Not Hispanic or Latino
    American Indian or Alaska Native (Not Hispanic or Latino
    Two or More Races (Not Hispanic or Latino)

VETERAN STATUS:(Please check one of the descriptions below corresponding to your veteran status – ifapplicable.)

    Vietnam Era Veteran
    Other Protected Veteran
    Armed Forces Service Medal Veterans

    Special Disabled Veteran
    Recently Separated Veteran

OTHER:

    Individual with Disabilities

    I do not wish to Self - Identify

Thank you for your participation
EEO: EEO-1 Voluntary Self Identification Form Rev 09/15 Confidential

Purpose :  Complete form L-4 so that your employer can withhold the correct amount of state income tax from your salary.

Instructions: Employees who are subject to state withholding should complete the personal allowances worksheet indicating the number of withholding personal exemptions in Block A and the number of dependency credits in Block B.

• Employees must file a new withholding exemption certificate within 10 days if the number of theire xemptions decreases, except if the change isther esult of the death of a spouse or a dependent.

Employees may file a new certificate any time the number of their exemptions increases.

• Line 8 should be used to increase or decrease the tax withheld for each pay period. Decreases should be indicated as anegative amount.

Penalties will be imposed for willfully supplying false information or willful failure to supply information that would reduce the withholding exemption.

This form must be filed with your emplo yer. If an employee failsto complet ethis withholding exemption cer tificate, the emplo yerm ust withhold Louisiana income tax from the employee’s wages without exemption.

Note to Employer: Keep this cer tificate withy our records. If you belie vethat an employee has improperly claimed toomanye xemptions or dependency credits,please forward a copy of the employee’s signed L-4 form with an explanation as to why you believe that the employee improperly completed thi form and any other supporting docu-mentation.The information should be sent to the Louisiana Department of Revenue, Criminal Investigations Division, PO Box 2389, Baton Rouge,LA70821-2389.

Block A

• Enter “0” to claim neither yourself nor your spouse, and check “No exemptions or dependents claimed” under number 3 below. You may enter “0” if you are married, and have a working spouse or more than one job to avoid having too little tax withheld.

• Enter“1” to claim yourself, and check “Single” under number 3 below. if you did not claim this exemption in connection with other employment, or if your spouse has not claimed your e xemption. Enter “1” to claim one personal exemption if you will file as head of household, and check “Single” under number 3 below.

• Enter “2” to claim yourself and your spouse, and check “Married” under number 3 below.

A

Block B

• Enter the number of dependents , not including yourself or your spouse, whom you will claim on your tax return. If no dependents are claimed, enter “0.”

B

Cut here and give the bottom portion of certificate to your employer. Keep the top portion for your records.

Form L- 4 Louisiana Department of Revenue

Employee’s Withholding Allowance Certificate

 No exemptions or dependents claimed

 Single

 Married

I declare under the penalties imposed for filing false reports that the number of exemptions and dependenc y credits claimed on this certificate do not exceed the number to which I am entitled.

The following is to be completed by employer.

DIRECT DEPOSIT AUTHORIZATION

Directions: To sign up for Direct Deposit, fill out Section 1. Then take this form to your financial institution.They must verify the information in Section 1. And complete Section 2. The completed form must be returned to CountryWide Staffing Solutions Group before Direct Deposit can be initiated. Please provide a copy of a voided check.

Section 1

I hereby authorize CountryWide Staffing Solutions Group to deposit funds into the account indicated below. I also authorize CountryWide Staffing Solutions Group, if necessary, to withdraw funds from the account below to correct any errors. This authority is to remain in full force and effective until CountryWide Staffing Solutions Group receives written notice from me to terminate the direct deposit, allowing a reasonable amount of time for CountryWide Staffing Solutions Group and the financial institution to act. I accept responsibility for notifying CountryWide Staffing Solutions Group of any change to my account’s status. I also understand that changes will take three (3) weeks and that regular (paper) checks will be distributed during this three-week period

Funds can only be deposited into one account, checking or savings. Please select your deposit account type:

Checking  
Savings  
Decline Deposite  
* This field is Required

SECTION 4

Please Enter Account Numbers

Instructions for Employment Eligibility Verification

Department of Homeland Security
U.S. Citizenship and Immigration Services

Read all instructions carefully before completing this form.

Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. 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. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc

What Is the Purpose of This Form?

Employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form I-9 CNMI between November 28, 2009 and November 27, 2011.

General Instructions

. Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors
Form I-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforcement (ICE).

Section 1. Employee Information and Attestation

Newly hired employees must complete and sign Section 1 of Form I-9 no later than the first day of employment . Section 1 should never be completed before the employee has accepted a job offer..

Provide the following information to complete Section 1:

Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any

Other names used: Provide all other names used, if any (including maiden name). If you have had no other legal names, write "N/A."

Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters from Canada or Mexico may use an international address in this field.

Date of Birth: Provide your date of birth in the mm/dd/yyyy format. For example, January 23, 1950, should be written as 01/23/1950.

U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security number is voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number.

E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephone number. Department of Homeland Security ( DHS) may contact you if DHS learns of a potential mismatch between the information provided and the information in DHS or Social Security Administration (SSA) records. You may write "N/A" if you choose not to provide this information.

All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking one of the following four boxes provided on the form:

1. A citizen of the United States

2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad

2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the "A" prefix

4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident, but are authorized to work in the United States, check this box

If you check this box:

a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, may write "N/A" on this line.

b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record your Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or as directed by USCIS or U.S. Customs and Border Protection (CBP)

(1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance)

(2) If you obtained your admission number from USCIS within the United States , or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance fields

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

Preparer and/or Translator Certification

The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement)

Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-274) on www.uscis.gov/ I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Section 2. Employer or Authorized Representative Review and Verification

Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer.

Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins employment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. An employer may complete Form I-9 before the first day of employment if the employer has offered the individual a job and the individual has accepted

Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page of Form I-9, to establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one selection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee must present combination documents together to be considered a List A document. For example, a foreign passport and a Form I-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. If an employee presents a List A document, he or she should not present a List B and List C document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the form should they get separated.

Employers or their authorized representative must:

1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents.

2. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number and expiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unused fields.

f the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employer should also enter in Section 2

a. The student's Form I-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number); and the program end date from Form I-20 or DS-2019.

3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first day the employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day of employment.

4. Provide the name and title of the person completing Section 2 in the Signature of Employer or Authorized Representative field.

5. Sign and date the attestation on the date Section 2 is completed.

6. Record the employer's business name and address.

7. Return the employee's documentation

Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should be made for ALL new hires or reverifications. Photocopies must be retained and presented with Form I-9 in case of an inspection by DHS or other federal government agency. Employers must always complete Section 2 even if they photocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place of completing Form I-9. Employers are still responsible for completing and retaining Form I-9.

Unexpired Documents

Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274) or I-9 Central ( www.uscis.gov/I-9Central ) for examples.

Receipts

If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form I-9 for a new hire or when reverification is required.

Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below.

There are three types of acceptable receipts:

1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The employee must present the actual document within 90 days from the date of hire.

2. The arrival portion of Form I-94/I-94A with a temporary I-551 stamp and a photograph of the individual. The employee must present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporary I-551 stamp, or, if there is no expiration date, within 1 year from the date of issue.

3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an unexpired Employment Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social Security card within 90 days.

When the employee provides an acceptable receipt, the employer should:

1. Record the document title in Section 2 under the sections titled List A, List B, or List C, as applicable.

Form I-9 Instructions 03/08/13 N Page 4 of 9 2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that the receipt is valid in the "Expiration Date" field.

By the end of the receipt validity period, the employer should:

1. Cross out the word "receipt" and any accompanying document number and expiration date.

2. Record the number and other required document information from the actual document presented.

3. Initial and date the change.

See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at www.uscis.gov/I-9Central for more information on receipts.

Section 3. Reverification and Rehires

Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized to work. When rehiring an employee within 3 years of the date Form I-9 was originally completed, employers have the option to complete a new Form I-9 or complete Section 3. When completing Section 3 in either a reverification or rehire situation, if the employee's name has changed, record the name change in Block A.

For employees who provide an employment authorization expiration date in Section 1, employers must reverify employment authorization on or before the date provided

Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766, Employment Authorization Document.

Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify:

1. U.S. citizens and noncitizen nationals; or

2. Lawful permanent residents who presented a Permanent Resident Card (Form I-551) for Section 2.

Reverification does not apply to List B documents.

If both Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the earlier date.

For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present.

To complete Section 3, employers should follow these instructions:

1. Complete Block A if an employee's name has changed at the time you complete Section 3

2. Complete Block B with the date of rehire if you rehire an employee within 3 years of the date this form was originally completed, and the employee is still authorized to be employed on the same basis as previously indicated on this form. Also complete the "Signature of Employer or Authorized Representative" block.

3. Complete Block C if:

a. The employment authorization or employment authorization document of a current employee is about to expire and requires reverification; or

b. You rehire an employee within 3 years of the date this form was originally completed and his or her employment authorization or employment authorization document has expired. (Complete Block B for this employee as well.)

To complete Block C:

a. Examine either a List A or List C document the employee presents that shows that the employee is currently authorized to work in the United States; and

b. Record the document title, document number, and expiration date (if any)

4. After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block, including the date

For reverification purposes, employers may either complete Section 3 of a new Form I-9 or Section 3 of the previously completed Form I-9. Any new pages of Form I-9 completed during reverification must be attached to the employee's original Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containing Section 3, with the employee's name entered at the top of the page, to the employee's original Form I-9. If there is a more current version of Form I-9 at the time of reverification, you must complete Section 3 of that version of the form

What Is the Filing Fee?

There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Act Statement" below

What Is the Filing Fee?

There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the "USCIS Privacy Act Statement" below

You can also obtain information about Form I-9 from the USCIS Web site at www.uscis.gov/I-9Central , by e-mailing USCIS at I-9Central@dhs.gov , or by calling 1-888-464-4218 . For TDD (hearing impaired), call 1-877-875-6028

To obtain USCIS forms or the Handbook for Employers , you can download them from the USCIS Web site at www.uscis. gov/forms . You may order USCIS forms by calling our toll-free number at 1-800-870-3676 . You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375-5283 . For TDD (hearing impaired), call 1-800-767-1833

Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from the USCIS Web site at www.dhs.gov/E- Verify , by e-mailing USCIS at I-9Central@dhs.gov or by calling 1-888-464-4218 . For TDD (hearing impaired), call 1-877-875-6028.

Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781 . For TDD (hearing impaired), call 1-877-875-6028

Photocopying and Retaining Form I-9

A blank Form I-9 may be reproduced, provided all sides are copied. The instructions and Lists of Acceptable Documents must be available to all employees completing this form. Employers must retain each employee's completed Form I-9 for as long as the individual works for the employer. Employers are required to retain the pages of the form on which the employee and employer enter data. If copies of documentation presented by the employee are made, those copies must also be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the date of hire or 1 year after the date employment ended, whichever is later

Form I-9 may be signed and retained electronically, in compliance with Department of Homeland Security regulations at 8 CFR 274a.2

USCIS Privacy Act Statement

AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324a).

PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

DISCLOSURE: : Submission of the information required in this form is voluntary. However, failure of the employer to ensure proper completion of this form for each employee may result in the imposition of civil or criminal penalties. In addition, employing individuals knowing that they are unauthorized to work in the United States may subject the employer to civil and/or criminal penalties.

ROUTINE USES: : This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The employer will keep this form and make it available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

Employment Eligibility Verification

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.)

Social Security

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):

OR
If you obtained your admission number from CBP in connection with your arrival in the United States, include the following:
Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. ( See instructions )

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



Waiver of Group Health Benefits

Please complete the following:

(ID Social Security Or Employee#)

 Myself
 Spouse/Domestic Partner
 Dependent (s) - Please list names:
* This field is Required
 My preference not to have coverage
 Coverage under my spouse’s/domestic partner’s plan name of carrier:
 Other coverage - name of carrier:
* This field is Required
.
 Individual
 COBRA
 Medicare
 TRICARE(formerly CHAMPUS)
 Medicaid
 Employer-Sponsored Group Plan

Special Enrollment Notice and Certification . Please review and sign below if you wish to waivecoverage

By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage (or if the employer stops contributing towards my or my eligible dependents’ other coverage).

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.

In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my human resources representative.

Form W-4 (2015)

Purpose. Complete Form W-4 so that youremployer can withhold the correct federal incometax from your pay. Consider completing a newForm W-4 each year and when your personal or financial situation changes.

Exemption from withholding. If you areexempt, only lines 1, 2, 3, 4, and 7and sign the form to validate it. Your exemptionfor 2015 expires February 16, 2016. SeePub. 505, Tax Withholding and Estimated Tax.

Note. If another person can claim you as adependent on his or her tax return, you cannot claim exemption fromwithholding if your income exceeds $1,050 and includes more than $350 of unearnedincome (for example, interest and dividends).

Exceptions. employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee: • Is age 65 or older, • Is blind, or • Will claim adjustments to income; tax credits; or itemized deductions, on his or her tax return.
The exceptions do not apply to supplemental wages greater than $1,000,000.

Basic instructions. you are not exempt,complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjustyour withholding allowances based on itemized deductions, certain credits, adjustments toincome, or two-earners/multiple jobs situations. Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

Head of household. Generally, you can claimhead of household filing status on your taxreturn only if you are unmarried and pay morethan 50% of the costs of keeping up a homefor yourself and your dependent(s) or otherqualifying individuals. See Pub. 501,Exemptions, Standard Deduction, and FilingInformation, for information.

Tax credits. You can take projected taxcredits into account in figuring your allowablenumber of withholding allowances. Credits forchild or dependent care expenses and thechild tax credit may be claimed using the Personal Allowances Worksheet below. SeePub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amountof nonwage income, such as interest ordividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.

Two earners or multiple jobs. If you have aworking spouse or more than one job, figure the total number of allowances you are entitledto claim on all jobs using worksheets from onlyone Form W-4. Your withholding usually willbe most accurate when all allowances are claimed on the Form W-4 for the highestpaying job and zero allowances are claimed onthe others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental FormW-4 Instructions for Nonresident Aliens, beforecompleting this form.

Check your withholding. After your Form W-4takes effect, use Pub. 505 to see how the amount you are having withheld compares toyour projected total tax for 2015. See Pub.505, especially if your earnings exceed$130,000 (Single) or $180,000 (Married).

Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4

Personal Allowances Worksheet (Keep for your records.)

Employee's Withholding Allowance Certificate

Deductions and Adjustments Worksheet

Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Deductions and Adjustments Worksheet

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)

Note. Use this worksheet only if the instructions under line H on page 1 direct you here.

1.
2.
3.

Note. If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4.
5.
6.
7.
8.
9.

NC-4 Employee’s Withholding Allowance Certificate

PURPOSE- Complete Form NC-4, Employee's Withholding Allowance Certificate, so that your employer can withhold the correct amount of State income tax from your pay. If you do not provide an NC-4 to your employer, your employer is required to withhold based on single with zero allowances

FORM NC-4 EZ - You may use this form if you intend to claim either: exempt status, or the N.C. standard deduction and no tax credits or only the credit for children.

FORM NC-4 NRA - If you are a nonresident alien you must use Form NC-4 NRA.

FORM NC-4 BASIC INSTRUCTIONS - Complete the Allowance Worksheet. The worksheet will help you figure the number of withholding allowances you are entitled to claim. The worksheet is provided for employees to adjust their withholding allowances based on N.C. itemized deductions, federal adjustments to income, N.C. additions to federal adjusted gross income, N.C. deductions from federal adjusted gross income, and N.C. tax credits. However, you may claim fewer allowances if you wish to increase the tax withheld during the year. If your withholding allowances decrease, you must file a new NC-4 with your employer within 10 days after the change occurs. Exception: When an individual ceases to be head of household after maintaining the household for the major portion of the year, a new NC-4 is not required until the next year.

TWO OR MORE JOBS - If you have more than one job, figure the total number of allowances you are entitled to claim on all jobs using one Form NC-4 Allowance Worksheet. Your withholding will usually be most accurate when all allowances are claimed on the NC-4 filed for the higher paying job and zero allowances are claimed for the other. You should also refer to the Multiple Jobs Table to determine the additional amount to be withheld on line 2 of Form NC-4 (See Allowance Worksheet).

NONWAGE INCOME - If you have a large amount of nonwage income, such as interest or dividends, you should consider making estimated tax payments using Form NC-40 to avoid underpayment of estimated tax interest. Form NC-40 is available on our website at www.dornc.com under individual income tax forms.

HEAD OF HOUSEHOLD - Generally you may claim head of household status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. Note: "Head of Household" for State tax purposes is the same as for federal tax purposes.

QUALIFYING WIDOW(ER) - You may claim qualifying widow(er) status only if your spouse died in either of the two preceding tax years and you meet the following requirements:

1. Your home is maintained as the main household of a child or stepchild for whom you can claim a federal exemption; and
2. You were entitled to file a joint return with your spouse in the year of your spouse's death.

MARRIED TAXPAYERS - For married taxpayers, both spouses must agree as to whether they will each complete the Allowance Worksheet based on married filing jointly or married filing separately.

For married taxpayers completing the Allowance Worksheet based on married filing jointly, you will consider the sum of both spouses incomes, adjustments, additions, deductions, and credits on the Allowance Worksheet to determine the number of allowances.

For married taxpayers completing the worksheet on the basis of married filing separately, each spouse will consider only his or her portion of income, adjustments, additions, deductions, and credits on the Allowance Worksheet to determine the number of allowances.

All NC-4 forms are subject to review by the North Carolina Department of Revenue. Your employer may be required to send this form to the North Carolina Department of Revenue.

CAUTION: If you furnish an employer with an Employee's Withholding Allowance Certificate that contains information which has no reasonable basis and results in a lesser amount of tax being withheld than would have been withheld had you furnished reasonable information, you are subject to a penalty of 50% of the amount not properly withheld.

NC-4 Allowance Worksheet- Part 1

Answer all of the following questions for your filing status.

Single

If you answered "No" to all of the above, STOP HERE and enter ZERO (0) as total allowances on Form NC-4, Line 1. If you answered "Yes" to any of the above, you may choose to go to Page 2, Part II to determine if you qualify for additional allowances. Otherwise, enter ZERO (0) on Form NC-4, Line 1.

Married Filing Separately -

If you answered "No" to all of the above, STOP HERE and enter ZERO (0) as total allowances on Form NC-4, Line 1. If you answered "Yes" to any of the above, you may choose to go to Page 2, Part II to determine if you qualify for additional allowances. Otherwise, enter ZERO (0) on Form NC-4, Line 1.

Married Filing Separately -

If you answered "No" to all of the above, STOP HERE and enter ZERO (0) as total allowances on Form NC-4, Line 1. If you answered "Yes" to any of the above, you may choose to go to Page 2, Part II to determine if you qualify for additional allowances. Otherwise, enter ZERO (0) on Form NC-4, Line 1.

Head of Household

If you answered "No" to all of the above, STOP HERE and enter ZERO (0) as total allowances on Form NC-4, Line 1. If you answered "Yes" to any of the above, you may choose to go to Page 2, Part II to determine if you qualify for additional allowances. Otherwise, enter ZERO (0) on Form NC-4, Line 1.

Qualifying Widow(er)

If you answered "No" to all of the above, STOP HERE and enter THREE (3) as total allowances on Form NC-4, Line 1. If you answered "Yes" to any of the above, you may choose to go to Part II to determine if you qualify for additional allowances. Otherwise, enter THREE (3) on Form NC-4, Line 1.

1 .$
2 .$
3 .$
4 .$
5 .$
6 .$
7 .$
8 .$
9 .$
10 .$
11 .$
12 .$
13 .$
14 .$
15 .$
16 .$

NC-4 Allowance Worksheet Schedules

Important: If you cannot reasonably estimate the amount to enter in the schedules below, you should enter ZERO (0) on line 1, NC-4.

Schedule 1

Estimated N.C. Itemized Deductions

$
$
$
$
$
$

*The sum of your qualified mortgage interest and real estate property taxes may not exceed $20,000. For married taxpayers, the $20,000 limitation applies to the combined total of qualified mortgage interest and real estate property taxes claimed by both spouses, rather than to each spouse separately.

Schedule 2

Estimated Federal Adjustments to Income

Federal adjustments to income are the amounts that are deducted from total income claimed on your federal return. Adjustments to income may include:

$
$
$
$
$
$
$

Estimated State Deductions from Federal

Adjusted Gross Income to Consider for NC-4 Purposes

$
$
$
$

(Do not consider any amount of the portion of Bailey Retirement Benefits, Social Security Benefits, or Railroad Retirement Benefits included in Adjusted Gross Income.)

$

Schedule 3

Estimated State Additions to Federal

Adjusted Gross Income to Consider for NC-4 Purposes

$
$
$
$

Schedule 4

Estimated N.C. Tax Credits

$

Credit for Children
A taxpayer who is allowed a federal child tax credit under section 24 of the Internal Revenue Code is allowed a tax credit for each dependent child unless adjusted gross income exceeds the threshold amount shown below. The credit can be claimed only for a child who is under 17 years of age on the last day of the year.

Filing Status
Adjusted Gross Income
No. of Children
Credit Amount per Qualifying Child
Estimated Credit
Single

Up to $20,000

Over $20,000 and up to $50,000

Over $50,000


$125

$100

$0




Married Filing Jointly or
Qualifying Widow(er)

Up to $40,000

Over $40,000 and up to $100,000

Over $100,000


$125

$100

$0




Head of Household

Up to $32,000

Over $32,000 and up to $80,000

Over $80,000


$125

$100

$0




Married Filing Separately

Up to $20,000

Over $20,000 and up to $50,000

Over $50,000


$125

$100

$0




Additional Tax Credits and Carryovers

$
$
$
$
$
$
$
$
$

MISSIPPI EMPLOYEE'S WITHHOLDING EXEMPTION CERTIFICATE


CLAIM YOUR WITHHOLDING PERSONAL EXEMPTION

Marital Status
Personal Exemption Allowed
Amount Claimed

EMPLOYEE:

File this form with your employer. Otherwise you must withhold Mississippi income tax from the full amount of your wages

1. Single
Enter $6,000 as exemption
2.Marital Status
Check One
Spouse NOT employed: Enter $12,000
Spouse IS employed: Enter that part of $12,000 claimed by you in multiples of $500. See instructions 2(b) below .
3. Head of Family
Enter $9,500 as exemption. To qualify as head of family, you must be single and have a dependent living in the home with you. See instructions 2(c) and 2(d)below

EMPLOYER

Keep this certificate with your records . If the employee is believed to have claimed excess exemption, the Department of Revenue should be advised.
4. Dependents
You may claim $1,500 for each dependent*, other than for taxpayer and spouse, who receives chief support from you and who qualifies as a dependent for Federal income tax purposes. * A head of family may claim $1,500 for each dependents excluding the one which qualifies you as head of family. Multiply number of dependents claimed by you by $1,500. Enter amount claimed
5. Age and Blindnes
Age 65 or olderHusband Wife Single
Blind Husband Wife Single Multiply the number of blocks checked by $1,500. Enter the amount claimed . . Note: No exemption allowed for age or blindness for dependents.
6.TOTAL AMOUNT OF EXEMPTION CLAIMED - Lines 1 through 5
7. Additional dollar amount of withholding per pay period if agreed to by your employer
Military Spouses Residency Relief Act Exemption from Mississippi Withholding
8. If you meet the conditions set forth under the Service Member Civil Relief, as amended by the Military Spouses Residency Relief Act, and have no Mississippi tax liability, write "Exempt" on Line 8. You must attach a copy of the Federal Form DD-2058 and a copy of your Military Spouse ID Card to this form so your employer can validate the exemption claim

INSTRUCTIONS

1. The personal exemptions allowed:

(a) Single Individuals
(b)Married Individuals (Jointly)
(c)Head of family

$6,000
$12,000
$9,500

(d) Dependents
(e) Age 65 and Over
(f) Blindness

$1,500
$1,500
$1,500

2. Claiming personal exemptions:

(a) Single Individuals enter $6,000 on Line 1
(b) Married individuals are allowed a joint exemption of $12,000.
If the spouse is not employed, enter $12,000 on Line 2(a). If the spouse is employed, the exemption of $12,000 may be divided between taxpayer and spouse in any manner they choose - in multiples of $500. For example, the taxpayer may claim $6,500 and the spouse claims $5,500; or the taxpayer may claim $8,000 and the spouse claims $4,000. The total claimed by the taxpayer and spouse may not exceed $12,000. Enter amount claimed by you on Line 2(b).
(c) Head of Family
A head of family is a single individual who maintains a home which is the principal place of abode for himself and at least one other dependent. Single individuals qualifying as a head of family enter $9,500 on Line 3. If the taxpayer has more than one dependent, additional exemptions are applicable. See item (d).
(d) An additional exemption of $1,500 may generally be claimed for each dependent of the
taxpayer . A dependent is any relative who receives chief support from the taxpayer and who qualifies as a dependent for Federal income tax purposes. Head of family individuals may claim an additional exemption for each dependent excluding the one which is required for head of family status. For example, a head of family taxpayer has 2 dependent children and his dependent mother living with him. The taxpayer may claim 2 additional exemptions. Married or single individuals may claim an additional exemption for each dependent, but

should not include themselves or their spouse. Married taxpayers may divide the number of their dependents between them in any manner they choose; for example, a married couple has 3 children who qualify as dependents. The taxpayer may claim 2 dependents and the spouse 1; or the taxpayer may claim 3 dependents and the spouse none. Enter the amount of dependent exemption on Line 4.
(e) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if either or both have reached the age of 65 before the close of the taxable year . No additional exemption is authorized for dependents by reason of age. Check applicable blocks on Line 5.
(f) An additional exemption of $1,500 may be claimed by either taxpayer or spouse or both if either or both are blind . No additional exemption is authorized for dependents by reason of blindness. Check applicable blocks on Line 5. Multiply number of blocks checked on Line 5 by $1,500 and enter amount of exemption claimed
3. Total Exemption Claimed: Add the amount of exemptions claimed in each category and enter the total on Line 6. This amount will be used as a basis for wit hholding income tax under the appropriate withholding tables.
4. A NEW EXEMPTION CERTIFICATE MUST BE FILED WITH YOUR EMPLOYER WITHIN 30 DAYS AFTER ANY CHANGE IN YOUR EXEMPTION STATUS .
5. PENALTIES ARE IMPOSED FOR WILLFULLY SUPPLYING FALSE INFORMATION
6. IF THE EMPLOYEE FAILS TO FILE AN EXEMPTION CERTIFICATE WITH HIS EMPLOYER, INCOME TAX MUST BE WITHHELD BY THE EMPLOYER ON TOTAL WAGES WITHOUT THE BENEFIT OF EXEMPTION.
7 . To comply with the Military Spouse Resi dency Relief Act (PL111-97) signed on November 11, 2009.

3505 Cadillac Ave, Suite O-201, Costa Mesa, CA 92626
Phone: (844) 322-6632 Fax: (714) 241-9279

MEC CHOICE EMPLOYEE ENROLLMENT FORM

EMPLOYER INFORMATION

EMPLOYEE INFORMATION

Male Female
MEC Decline

DEPENDENT CHILDREN INFORMATION (Spouses ineligible)

First Name
Last Name
DOB
Sex
Social Security
Relationship
Plan Choice
MF
Child
MECDecline
MF
Child
MECDecline
MF
Child
MECDecline
MF
Child
MECDecline
MF
Child
MECDecline

LEGAL ACKNOWLEDGMENT

1)I understand that if the aboveinformation is notcomplete or correct this coverage could be retroactively terminated
Initial
2) I understand that if I decline coverage now and later want to enroll myself or my dependents, I may only be able to add coverage for myself or my dependents if I enroll for coverage within 30 days of a HIPAA Special Enrollment Event or at the next Open Enrollment Period.
Initial
3) I understand that enrollment in either the Minimum Essential Coverage (MEC) or the MV Lite Coverage is required in order to avoid the Individual Mandate Penalty of the Affordable Care Act. By declining this coverage I may be responsible for a penalty of 2% of my income or $325 per person in my family in 2015.
Initial
4) I understand that I may decline this plan and still be eligible to receive a subsidy for a plan in the State Healthcare Exchange. I have the option to purchase a plan from the Exchange and I may also be eligible for MediCal/MedicAid
Initial
5) I understand that the MEC and MV Lite plans are not traditional insurance plans and may exclude some coverage traditionally associated with health insurance plans. The MECplan only covers preventative services and the MV Lite plan excludes services such as hospitalization, surgery, maternity, etc
Initial
6) I understand I will be charged $7.33 per week for my own coverage and $7.33 per week per dependent child I add to my coverage
Initial

KENTUCKY DEPARTMENT OF REVENUE

EMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE


EMPLOYEE:
Failure to file this form with
your employer will result in
withholding tax deductions
from your wages at the
maximum rate.





EMPLOYER:Keep this certificate with your records.

8. Additional withholding per pay period under agreement with employer. See instruction 1 $

INSTRUCTIONS

1. NUMBER OF EXEMPTIONS —Do not claim more than the correct number of exemptions. However, if you have unusually large amounts of itemized deductions, you may claim additional exemptions to avoid excess withholding. You may also claim an additional exemption if you will be a member of the Kentucky National Guard at the end of the year. If you expect to owe more income tax for the year than will be withheld, you may increase the withholding by claiming a smaller number of exemptions or you may enter into an agreement with your employer to have additional amounts withheld. If you claim more than 10 exemptions this information is sent to the Department of Revenue. 2. CHANGES IN EXEMPTIONS —You may file a new certificate at any time if the number of your exemptions INCREASES . You must file a new certificate within 10 days if the number of exemptions previously claimed by you DECREASES for any of the following reasons. (a) You are divorced or legally separated from your spouse for whom you have been claiming an exemption or your spouse claims his or her own exemption on a separate certificate. (b) The support of a dependent for whom you claimed exemption is taken over by someone else, so that you no longer expect to furnish more than half the support for the year. (c) Your itemized deductions substantially decrease and a Form K-4A has previously been filed. OTHER DECREASES in exemption, such as the death of a spouse or a dependent, do not affect your withholding until the next year, but require the filing of a new certificate by December 1 of the year in which they occur.
3. DEPENDENTS —To qualify as your dependent (line 4 on reverse), a person (a) must receive more than one-half of his or her support from you for the year, and (b) must not be claimed as an exemption by such person’s spouse, and (c) must be a citizen of the United States, or a resident of the United States, Canada, or Mexico, or (d) must have lived with you for the entire year as a member of your household or be related to you as follows: • your child, stepchild, legally adopted child, foster child (if he lived in your home as a member of the family for the entire year), grandchild, son-in-law, or daughter-in-law; • your father, mother, or ancestor of either, stepfather, stepmother, father-in- law, or mother-in-law; • your brother, sister, stepbrother, stepsister, brother-in-law, or sister-in-law; • your uncle, aunt, nephew, or niece (but only if related by blood). 4. PENALTIES —Penalties are imposed for willfully supplying false information or willful failure to supply information which would reduce the withholding exemption

FORM
A4
(REV:)

ALABAMA DEPARTMENT OF REVENUE
50 North Ripley Street • Montgomery, AL 36104 • InfoLine (334) 242-1300
www.revenue.alabama.gov

Employee's WithHolding Tax Exception Certificate

Every employee, on or before the date of commencement of employment, shall furnish his or her employer with a signed Alabama with- holding exemption certificate relating to the number of withholding exemptions which he or she claims, which in no event shall exceed the number to which the employee is entitled. In the event the employee inflates the number of exemptions allowed by this Chapter on Form A4, the employee shall pay a penalty of five hundred dollars ($500) for such action pursuant to Section 40-29-75.

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. If you claim no personal exemption for yourself and wish to withhold at the highest rate, write the figure “0”,
sign and date Form A4 and file it with your employer.

2. If you are SINGLE or MARRIED FILING SEPARATELY, a $1,500 personal exemption is allowed.
Write the letter “S” if claiming the SINGLE exemption or “MS” if claiming the MARRIED FILING SEPARATELY exemption.......

3. If you are MARRIED or SINGLE CLAIMING HEAD OF FAMILY, a $3,000 personal exemption is allowed.
Write the letter “M” if you are claiming an exemption for both yourself and your spouse or “H” if you are
single with qualifying dependents and are claiming the HEAD OF FAMILY exemption

4. Number of dependents (other than spouse) that you will provide more than one-half of the support for during the year. See dependent qualification below.

5. Additional amount, if any, you want deducted each pay period

$

6. This line to be completed by your employer: Total exemptions (example: employee claims “M” on line 3 and “2” on line 4. Employer should use column M-2 (married with 2 dependents) in the withholding tables)

Under penalties of perjury, I certify that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.

Part B To Be Completed by the Employer

Employers are required to keep this certificate on file. If the employee is believed to have claimed more exemption than legally entitled or claims 8 or more dependent exemptions, the employer should contact the Department at the following address or phone number for ver- ification: Alabama Department of Revenue, Withholding Tax Section, P.O. Box 327480, Montgomery, AL 36132-7480, by phone at (334) 242-1300, or by fax at (334) 242-0112. If the employee does not qualify for the exemptions claimed upon verification, the employer is re- quired to withhold at the highest rate until the employee submits a corrected Form A4 reflecting the proper exemption they are entitled to claim.

DEPENDENTS:To qualify as your dependent (Line 4 above), a person must receive more than one-half of his or her support from you for the year and must be related to you as follows:
Your son or daughter (including legally adopted children), grandchild, stepson, stepdaughter, son-in-law, or daughter-in-law;
Your father, mother, grandparent, stepfather, stepmother, father-in-law, or mother-in-law;
Your brother, sister, stepbrother, stepsister, half-brother, half-sister, brother-in-law, or sister-in-law;
Your uncle, aunt, nephew, or niece (but only if related by blood)

THIS FORM MAY BE REPRODUCED

STATE OF GEORGIA EMPLOYEE'S WITHHOLDING ALLOWANCE CERTIFICATE

Please Read Instructions on reverse side before completing lines 3-8

3.MARITAL STATUS

(If you do not wish to claim an allowance, enter “0” in the brackets beside your marital status.)

A.Single:Enter 0 or 1..............[]
B.Married filling joint,both spouse working
  Enter 0 or 1 or 2..............[]
C.Married filling joint,both spouse working
  Enter 0 or 1 or 2..............[]
D.Married filling joint,both spouse working
  Enter 0 or 1 or 2..............[]
E.Married filling joint,both spouse working
  Enter 0 or 1 or 2..............[]

4.DEPENDENT ALLOWANCES []


5.ADDITIONAL ALLOWANCES []


6. ADDITIONAL WITHHOLDING $

WORKSHEET FOR CALCULATING ADDITIONAL ALLOWANCES
(Must be completed only if step 5 is greater than zero)

1.COMPLETE THIS LINE ONLY IF USING STANDARD DEDUCTION:

Number of boxes Checked x 13......$

2. ADDITIONAL ALLOWANCES FOR DEDUCTIONS:

(This is the maximum number of additional allowances you can claim. If the remainder is over $1,500 round up)

(Employer: The letter indicates the tax tables in the Employer’s Tax Guide)

8. EXEMPT:(Do not complete Lines 3 - 7 if claiming exempt)Read the Line 8 instructions on page 2 before completing this section.
a) I claim exemption from withholding because I in curred no Georgia income tax liability last year and I do not expect to have a Georgia income tax liability this year. Check here

b) I certify that I am not subject to Georgia withholding because I meet the conditions set forth under the Servicemembers Civil Relief Act as amended by the Military Spouses Residency Relief Act as provided on page 2. My state of residence is My spouse’s (servicemember) state of residence is The states of residence must be the same to be exempt. Check here

Employer: Complete Line 9 and mail entire form only if the employee claims over 14 allowances or exempt from withholding. If necessary, mail form to: Georgia Department of Revenue, Withholding Tax Unit, P. O. Box 49432, Atlanta, GA 30359.

Do not accept forms claiming additional allowances unless the worksheet has been completed. Do not accept forms claiming exempt if numb ers are written on Lines 3 - 7.

INSTRUCTIONS FOR COMPLETING FORM G-4

Enter your full name, address and social security number in boxes 1a through 2b. Line 3: Write the number of allo wances you are claiming in the brack ets beside your marital status.     A. Single - enter 1 if you are claiming yourself      B. Married Filing Joint, both spouses working - enter 1 if you claim yourself or 2 if you claim yourself and your spouse     C. Married Filing Joint, one spouse working - enter 1 if you claim yourself or 2 if you claim yourself and your spouse     D. Married Filing Separate - enter 1 if you claim yourself or 2 if you claim yourself and your spouse     E. Head of Household - enter 1 if you claim yourself but the individual(s) for whom you maintain a home does not qualify as a dependent; or 2 if you claim yourself and a qualified dependent for whom you maintain a home Do not claim a deduction on Line 4 for a depende nt used to qualify you as head of household     Line 4: Enter the number of dependent allowances you are entitled to claim.     Line 5: Complete the worksheet on Form G-4 if you claim additional allowances. Enter the number on Line H here. Failure to complete and submit the worksheet w ill result in automatic denial of your claim.     Line 6: Enter a specific dollar amount that you authorize your employer to withhold in addition to the tax withheld based on y our marital status and number of allowances.     Line 7: Enter the letter of your marital status from Line 3. Enter total of the numbers on Lines 3 - 5.     Line 8: a) Check the first box if you qualify to claim exempt from withholding. You can claim exempt if you filed a Georgia income tax return last year and the amount on Line 4 of Form 500EZ or Line 16 of Form 500 was zero, and you expect to file a Georgia tax return this year and will not have a tax liability. You can not claim exempt if you did not file a Georgia income tax return for the previous tax year. Receiving a refund in the previous tax year does not qualify yo u to claim exempt. EXAMPLES: Your employer withheld $500 of Georgia income tax from your wages. The amount on Line 4 of Form 500EZ (or Line 16 of Form 500) was $100. Your tax liability is the amount on Line 4 (or Line 16); therefore, you do not qualify to claim exempt. Your employer withheld $500 of Georgia income tax from your wages. The amount on Line 4 of Form 500EZ (or Line 16 of Form 500) was $0 (zero). Your tax liability is the amount on Line 4 (or Line 16) and you filed a prior year income tax return; therefore, you qualify to claim exempt. b) Check the second box if you are not subject to Georgia withholding and meet the conditions set forth under the Servicemembers Civil Relief Act, as amended by the Military S pouses Residency Relief Act. Under the Act, a spouse of a servicemember may be exempt from Georgia income tax on income from services performed in Georgia if:     1. The servicemember is present in Georgia in compliance with military orders;     2. The spouse is in Georgia solely to be with the servicemember;     3. The spouse maintains domicile in another state; and     4. The domicile of the spouse is the sa me as the domicile of the servicemember. Additional information for employers regardin g the Military Spouses Residency Relief Act: 1. On the W-2 for 2009, the employer should report all wages earned during the year as Georgia wages. On the W-2 for 2010 and any year thereafter, the employer should not report any of the wages as Georgia wages on the W-2. 2. If the spouse of a servicemember is entitled to the protection of the Military Spouses Residency Relief Act in another state and files a withholding exemption form in such other state, the spouse is required to submit a Georgia Form G-4 so that withholding will occur as is required by Georgia Law when a Georgia domiciliary works in another state and withholding is not required by such other state. If the spouse does not fill out the form, the employer sha ll withhold Georgia income tax as if the spouse is single with zero allowances. Do not complete Lines 3 - 7 if claiming exempt. O.C.G.A. § 48-7-102 requires you to complete and submit Form G-4 to your employer in order to have tax withheld from your wages. By correctly completing this form, you can adjust the amount of tax withheld to meet your tax liability. Failure to submit a pr operly completed Form G-4 will result in your employer withholding tax as though you are single with zero allowances. Employers are required to mail any Form G-4 claiming more than 14 allowances or exempt from withholding to the Georgia Department of Revenue for approval. Employers will honor the prop erly completed form as submitted pending notification from the Withholding Tax Unit. Upon approval, such forms remain in eff ect until changed or until February 15 of the following year. Employers who know that a G-4 is erroneous should not honor the fo rm and should withhold as if the employee is single claiming zero allowances until a corrected form has been received.