Bluegrass Community & Technical College

Revised 1/2017

New Employee Checklist ADJUNCT FACULTY

Name: _______________________________

Employee ID: __________________

**SUBMIT THIS COMPLETED FORM & ACCOMPANYING DOCUMENTS

TO HUMAN RESOURCES**

HR Documents Payroll Documents

Background Check Request Sent to HR W4 Federal Tax Form

Background Approval from HR

K4 KY State Tax Form

Signed Employment Contract(s)

Direct Deposit Form

Application Voided Check

Original Resume/Vitae (if applicable)

Transcript(s)

*Required – Submit to Karen Dearborn*

EEO-1 Voluntary Self Identification Form (optional)

Drug-Free Policy Notification (HR123)

Computer Account Usage Agreement (HR111)

HR Policy Handbook Acknowledgement Form (HR104)

Personal Data Sheet (HR96)

Harassment-Free Workplace Brochure Acknowledgement Form (HR 120)

Nepotism Disclosure Form (HR112)

Workers’ Compensation Guide to Possible Biohazards Form (HR105)

KTRS All New Hires and P/T Employee Form (HR 114)

Employment Disclosure – Patient Protection and ACA Eligibility Form (HR 125)

Notice: New Health Insurance Marketplace Coverage Options

(Give to employee; for information purposes only)

OSHA Mandatory Training (Give to employee – must be completed within 30 days)

Completed I-9, with supporting documents

KCTCS (Rev. 07/2008)

KCTCS is an Equal Opportunity/Affirmative Action Employer and has an affirmative duty to reasonably accommodate otherwise qualified individuals with a disability.

(Please Print or Type) Date of Application ____________________________________

Use blue or black ink

Name:

Last First Middle Preferred

Address:

Number Street City County State ZIP Code

Telephone: ( ) Last Four Digits of Social Security Number __ __ __ __

Email Address ______________________________________________

Have you ever been employed by this college or another KCTCS college? Yes NoIf yes, please provide the following:

Name: ______________________________ Date(s) employed: ____________________ College/Office: _______________

Does your citizenship or immigration status lawfully allow you to be employed in this country? (Proof of citizenship or immigration status will be required upon employment.) Yes No If no, state type of Visa: ___________

Student Status: Full-time Part-time Number of hours: _____

Classification: FR SOPH Non-Degree

Major: Minor: Anticipated Graduation/Completion date:

(Circle response) Shifts you would accept - Days Nights Evenings Weekends On Call

Total number of hours you would like to work per week: ____

Indicate the hours you are available to work below.

Monday Tuesday Wednesday Thursday Friday

A.M.

P.M.

References List three references not related to you.

Name Address Telephone

For employees related by blood or marriage to work at the Kentucky Community and Technical College System in the same department or division, we require specific approval of the Chancellor or KCTCS President as appropriate. Also, in most cases where we employ you and a person related to you by blood or marriage, neither of you can have supervisory or line authority over the other.

Do you have any relatives employed by KCTCS? Yes NoIf yes, provide the following:

Name ___________________________________________________ Relationship _____________________________________________

College Employed by _______________________________________ Job Title _________________________________________________

KRS 164.600(8) states that "no citizen member of the board of directors shall be a relative of any employee of the community college under its jurisdiction."

Application For Temporary or

Student Employment

Education and Training (Attach a page or resume if additional space is needed.)

Credentials

Print Name, Number & Street City, State, Zip Code for each

Dates

Attended

Type of Courses

Major-Minor

Credits Earned

Degree or Credential Obtained

High School/

G.E.D./ Certificate

Postsecondary

/ College

Employment History Starting with the most recent position, list below any previous employers, including volunteer work. (Attach a page or resume if

additional space is needed.)

Employment Data Employment Data (1) Employer

(3) Employer

Job Title

Job Title

Full-Time or Part-Time Hours per week Salary (circle one) wk/hr

Full-Time or Part-Time Hours per week Salary (circle one) wk/hr

Dates Employed

Dates Employed

(2) Employer

(4) Employer

Job Title

Job Title

Full-Time or Part-Time Hours per week Salary (circle one) wk/hr

Full-Time or Part-Time Hours per week Salary (circle one) wk/hr

Dates Employed

Dates Employed

Have you ever been discharged from any position? _______ If so, why? ___________________________________________

Special licenses, certificates, or foreign languages: ____________________________________________________________

Check the following computer skills and office equipment in which you are comfortable utilizing:

MS Word Excel Access PowerPoint Internet/html MS Outlook PageMaker

Typewriter Fax machine Xerox Scanner

FOR THIS TYPE OF EMPLOYMENT, STATE LAW REQUIRES A STATE AND NATIONAL CRIMINAL HISTORY BACKGROUND CHECK AS A CONDITION OF EMPLOYMENT.

Have you ever been convicted of a felony? Yes No

If yes, please explain giving dates, location(s), and full name at the time: __________________________________________

___________________________________________________________________________________________________

AGREEMENT I CERTIFY THAT ALL ANSWERS TO THE QUESTIONS IN THIS APPLICATION ARE TRUE, AND I FURTHER UNDERSTAND THAT ANY FALSE STATEMENTS AND/OR OMISSION IN THIS APPLICATION WILL BE SUFFICIENT GROUNDS FOR REJECTION OF THE APPLICATION, OR TERMINATION OF EMPLOYMENT WITHOUT NOTICE.

I AUTHORIZE THE KENTUCKY COMMUNITY AND TECHNICAL COLLEGE SYSTEM (KCTCS) TO MAKE ANY AND ALL-NECESSARY AND APPROPRIATE INVESTIGATIONS TO VERIFY THE INFORMATION CONTAINED HEREIN, INCLUDING CRIMINAL RECORDS, EDUCATIONAL CREDENTIALS AND WORK EXPERIENCE CHECKS. REFERENCES OBTAINED ARE DONE SO IN CONFIDENCE AND I UNDERSTAND THAT MY RIGHTS TO REVIEW ANY REFERENCE MATERIAL IS WAIVED.

PRIOR TO EMPLOYMENT, I MUST PROVIDE INFORMATION RELATED TO IDENTITY AND EMPLOYABILITY. FAILURE TO PROVIDE APPROPRIATE DOCUMENTATION FOR VERIFICATION OF EMPLOYMENT ELIGIBILITY SHALL RESULT IN IMMEDIATE TERMINATION OF EMPLOYMENT AND/OR ANY OFFER OF EMPLOYMENT.

Signature of Applicant Date

EEO-1 Voluntary Self Identification Form

The Equal Employment Opportunity Commission (EEOC) requires organizations with 100 or

more employees to invite applicants to self-identify gender and race and complete an EEO-1

report each year. Completion of this data is voluntary and will not affect your opportunity for

employment, or terms or conditions of employment. This form will be used for EEO-1 reporting

purposes only and will be kept separate from all other personnel records only accessed by the

Human Resources department. Please return completed forms to the HR department.

NAME: __________________________________

JOB TITLE: ________________________________

GENDER (Please check one of the options below)

_____ Male

_____ Female

RACE/ETHNICITY (Please check one of the descriptions below corresponding to the ethnic

group with which you identify.)

___ Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American,

or other Spanish culture or origin regardless of race.

___ White (Not Hispanic or Latino): A person having origins in any of the original peoples of

Europe, the Middle East or North Africa.

___ Black or African American (Not Hispanic or Latino): A person having origins in any of the

black racial groups of Africa.

___ Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino): A person having origins

in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands.

___ Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the

Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China,

India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.

___ American Indian or Alaska Native (Not Hispanic or Latino): A person having origins in any

of the original peoples of North and South America (including Central America) and who

maintains tribal affiliation or community attachment.

___Two or more races (Not Hispanic or Latino): All persons who identify with more than one of

the above five races.

Date completed: ___________________________

Please return form to the HR department. Thank you for your participation.

HR123

Kentucky Community & Technical College System

Revised 02/2002; 09/2009 Human Resources Procedure 3.3.13

Drug-Free Policy Notification The Federal Drug-Free Workplace Act of 1988 (Section 5151) requires that all employees receive a copy of the statement, which certifies that the Kentucky Community and Technical College System (KCTCS) is a drug-free workplace. This policy notification and the signed statement (below) insure KCTCS’s compliance with the federal law. For purposes of the law and this policy, drug is defined as “a ‘controlled substance’, which means any controlled substance in schedules I through V of section 2020 of the Controlled Substance Act, which, in turn, means virtually every controlled substance from the worst street drugs to mild prescription drugs; however, the two substances not covered are alcohol and tobacco products.” The entire text of KCTCS’s policy and procedures for being a drug-free workplace is contained in KCTCS Administrative Policies and Procedures 3.3.13: KCTCS Substance Abuse. KCTCS is committed to providing a drug-free workplace for its employees. Accordingly, it is a violation of KCTCS policy for an employee to unlawfully manufacture, distribute, dispense, or use a controlled substance while in the workplace or on KCTCS business. It is KCTCS policy that a violation of the above shall result in appropriate action up to and including suspension or dismissal. Additionally, KCTCS has a drug-free awareness program, which includes educational programs and general information on the following:

1. The dangers of drug use and abuse in the workplace; 2. The details of KCTCS’s Substance Abuse Policy (KCTCS Administrative Policies and Procedures

3.3.13); and 3. The availability of drug counseling, rehabilitation and employee assistance programs.

KCTCS Administrative Policies and Procedures 3.3.13.1.2, Legal Use of Prescribed Medicines, states: The legal use of prescribed medicines under the direction of a licensed physician is permitted. Employees in selected positions, designated by KCTCS, are required to make such use known to an appropriate KCTCS representative, as described in college standard operating procedures. Employees using prescribed medicines should consult with a physician concerning the safe use of the drug(s) during working hours. After reading this policy notification, please read and sign the following certification. This document will be placed in your personnel file in the Human Resources office.

Drug-Free Workplace Policy Certification In accordance with federal law and KCTCS policy, I understand the following:

1. That I shall notify my immediate supervisor within five (5) days of my conviction of any criminal drug statute violation which occurred in the workplace or while on KCTCS business;

2. That, if I am employed on a federal or state grant or contract, KCTCS shall notify the granting or contracting agency within ten (10) days of receiving notice of my conviction; and

3. That KCTCS shall take appropriate action, as outlined in KCTCS Administrative Policies and Procedures 3.3.13, within thirty (30) days of receiving notice of my conviction.

I have read carefully the policy notification and the above. I fully understand the information and requirements contained herein. I further understand that failure to abide by KCTCS’s Substance Abuse Policy may result in my being required to participate satisfactorily in a drug abuse assistance/rehabilitation program and/or in disciplinary action up to and including suspension or dismissal.

Signature Date Employee ID

Print Full Name College/Department/Division

HR111

Kentucky Community & Technical College System

Revised 09/2009 Human Resources Policy 4.2.5 and 4.2.5.7

Computer Account Usage Agreement

I acknowledge responsibility for the use of all the computer accounts assigned to me on the KCTCS centralized computing systems. I will accept any and all consequences due to the misuse or abuse of the computing facilities. I agree to:

• use the computing facilities in an appropriate and ethical manner;• abide by software copyright agreements and to respect the property rights and associated

restrictions of others and to refrain from actions or access which would violate the terms of suchlicensing and nondisclosure agreements;

• respect the confidentiality of data, complying with federal and state statutes and KCTCS policiesregarding access to KCTCS data and to not release such data without proper authorization;

• take appropriate steps to safeguard access codes and passwords to protect against unauthorizeduse and to notify Information Technology of suspected unauthorized use;

• not make unauthorized use of the accounts and to not knowingly grant use of the accounts forunauthorized purposes;

• respect the rights of all other users of the system and to not knowingly use computing resources inany way which is disruptive or damaging to the system or any other user;

• not use the electronic communication facilities in any way to offend, annoy or harass other users;• the proper management of computing resources, not limited to but including disk space and tape

volumes;• take proper precautions to safeguard personal data for recovery in the event of a computing

system disaster.

I understand KCTCS does not warrant the functionality or performance of the resources, made available by the use of the computer accounts, to meet my particular purposes or use and realize that I bear the risk of loss or damages arising therefrom.

I understand computing resources are the property of KCTCS and once my computer accounts are closed, access to the accounts or the data contained within them may be granted to others to facilitate the transfer of responsibility or the retrieval of data. An annual review and test of responsible use of information and information technology may be required.

I understand that misuse of the computing resources, abuse of the system, or other violation of this agreement, by me, or by an individual to whom I have permitted use of the computer accounts, can result in loss of computing privileges, disciplinary action, and legal action.

Employee Name (Print) Date

Employee Signature

Revised 9/15, 4/13; 9/09; 2/06;10/15 HR 104

Kentucky Community and Technical College System (“KCTCS”)

KCTCS ADMINISTRATIVE AND BOARD POLICIES

ACKNOWLEDGEMENT FORM

Pursuant to KRS 164.365, the KCTCS Board of Regents has exclusive control over employment, tenure, and official

relations of employees. The policies and procedures contained in the KCTCS Administrative and Board Policies are

not intended and should not be construed to create a contract of employment. It is the intention of KCTCS to

implement the Board’s human resources policies through procedures that are in compliance with state and federal

laws and that recognize any employment rights granted to employees by the Board. Employees hired under contract

are subject to applicable KCTCS policies and procedures as well as to the terms and conditions of the contract.

Please note the following:

(1) A complete set of human resources policies and other KCTCS policies are contained in the KCTCS

Administrative Policies and KCTCS Board Policies at

https://publicsearch.kctcs.edu/policies/Pages/KCTCSPolicies.aspx.

(2) All KCTCS employees are individually responsible initially at employment, and subsequently thereafter, to

perform a periodic review of the KCTCS Administrative Policies and KCTCS Board Policies.

(3) Revisions in the policies and procedures are also updated online. Employees are responsible for reviewing and

knowing the policies, procedures and subsequent revisions.

(4) All policies in the KCTCS Administrative Policies and KCTCS Board Policies govern all applicable employees in

each personnel system unless otherwise designated; and

(5) Your college and/or department may have additional human resources rules with which you are required to

comply.

Please sign below to indicate that you understand and acknowledge the above information, and that you have reviewed and

understand the policies contained in the KCTCS Administrative Policies and KCTCS Board Policies.

Acknowledged, signed, and dated by:

Employee Signature Date

Print Name College & Dept., or System Office Dept.

Date of Employment Position

FOR COLLEGE EMPLOYEES, PLEASE RETURN SIGNED FORM TO YOUR COLLEGE HUMAN RESOURCES DIRECTOR. A

COPY OF THE FORM WILL BE PUT IN THE EMPLOYEE’S PERSONNEL FILES AT THE COLLEGE AND AT THE SYSTEM

OFFICE. FOR SYSTEM OFFICE EMPLOYEES, PLEASE RETURN YOUR SIGNED FORM TO THE HUMAN RESOURCES

DEPARTMENT.

HUMAN RESOURCES STAFF SHOULD PROVIDE THE EMPLOYEE A SIGNED COPY OF THE FORM.

FORM HR96

[ ] Change of Address * *Note: A change of address can result in a change in local occupational tax

[ ] Change of Name ** [ ] Military Service Information [ ] New Hire [ ] Change of Emergency Contact

Effective Date of Action:________________________________

Employee Name (First, Middle, Last): *Current; or former in case of name change (new name indicated below)* College: (Required )

Address (Street Address, City, State, Zip): Note: PO Box cannot be entered as Home address, only a mailing address. MUST have an actual street address for home address. Employee ID#:

County of Residence: Phone Number (Home or Cell): Email Address:

( )

**Check One: o I wish my name to be changed only in PeopleSoft for Human Resource and Student Affairs records. My login ID and name display in global email will remain in the old/former name.

o I wish my name to be changed to reflect my new last name in the global email display only. My login ID will remain in the old/former name.

o I wish my name to be changed to reflect my new last name in the global email display AND my login ID.

*** REMEMBER TO FILE AN ADDRESS CHANGE WITH YOUR RETIREMENT VENDORS and HEALTH and LIFE INSURANCE CARRIERS, if applicable.

New Name:

Contact Name #1 Relationship:

Address (Street Address, City, State, Zip):

Home Phone Number: Employer: Work Phone Number: Cell Phone Number:

( ) ( ) ( )

Contact Name #2 Relationship:

Address (Street Address, City, State, Zip):

Home Phone Number: Employer: Work Phone Number: Cell Phone Number:

( ) ( ) ( )

Are you a member of the Armed Forces of the United States in any capacity which potentially makes you subject to a call to active duty (State or Federal)? [ ] Yes [ ] No

If so, please provide your unit designation (including your service e.g. National Guard or Coast Guard Reserve)

(Example: 2nd Battalion, 123rd Armor, Kentucky Army National Guard)

Employee Signature Date Address change (only) to Accounting Copy to Emer Contacts File Entered in PS by Date

*** Please send completed form to your college HR Office *** Forward completed form, once entered, to KCTCS System HR for inclusion in permanent file

S:\HR\HR Forms\PersDataForm,08.2010

Military Status

In the event of an emergency, or other situation, if we are unable to contact you directly KCTCS may need to contact a member of your family, or other individual(s).

This information will only be used in the case of an emergency and will be retained for use only by the Human Resources office.

Please list the names and appropriate contact information for two designated emergency contacts.

Current Action:

Personal Information

Emergency Contact Information

Name Change

Presentation of a new Social Security card is required for a name change. Please attach a photocopy of the new card issued in the new name.

Personal Data Sheet

Revised 6/29/06; 09/2009; 12/2014 Human Resources Policy 3.1 & 3.3.1

Bluegrass Community & Technical College

Harassment-Free Workplace Brochure

Acknowledgement Form

This acknowledgement form should be used for acknowledgement of the KCTCS Harassment-Free Workplace brochure.

By signing below you acknowledge receipt on and understanding of the KCTCS brochure on sexual harassment, entitled “Harassment-Free Workplace”.

In addition, you acknowledge that the KCTCS Policy Manual contains policies on illegal discrimination/ sexual harassment and the procedures for reporting any complaints and/or grievances concerning allegations of illegal harassment/discrimination.

Please be advised that you are required to complete the KCTCS online sexual harassment prevention training within 30 days of your employment. Upon hire, all new employees will be sent an email notification from KCTCS Training to their KCTCS email account.This email will include instructions, a user name and password. After completing the training you will be required to take the mastery test online. If you have not received an KCTCS email address from your supervisor, please contact the IT Help Desk (859) 246-4600 for further assistance.

All new hires must complete the online training course; subsequently, all employees may be required to complete the online training refresher course on an annual basis.

Employee Signature Date

Print Name Department

Date of Employment Position

HARASSMENT

FREE

WORKPLACE

Additional Assistance

For assistance outside your local

campus you may contact:

KCTCS Human Resources Department

300 North Main Street

Versailles, KY 40383

(859) 256-3322/3332

For additional information or

assistance you may also contact:

The Kentucky Commission

on Human Rights at 1-800-292-5566

or

The Equal Employment

Opportunity Commission

at 1-800-669-4000

KCTCSSEXUAL HARASSMENT POLICY*

It is the policy of the Kentucky Community and Technical College System (KCTCS) to provide a work environment that is pleasant, professional and free from illegal discrimination. Sexual harassment is a form of illegal discrimination and will not be tolerated at KCTCS.

Sexual harassment is an assault on a person’s privacy and integrity. It can cause poor job performance, physical illness, fear of reprisal, !"#$%&'()!"*)+,--),. )-%+. )/,"0*%"/%1))2%#3!+)harassment can also affect those exposed to the -$&3!&$,"()/!3-$"4)5,678+!/%)/,"9$/&()!)*%/+$"%)$")morale, and a loss of respect for the responsible party.

Any information reported concerning allegations of sexual harassment will be handled /,"0*%"&$!++')&,)&:%).3++%-&)%#&%"&)8,--$;+%1

* Applies to all employees regardless of employment

with predecessor institutions. Also applies to

discrimination in the form of harassment based upon

color, religion, national origin, sexual orientation,

disability, or age.

HUMAN RESOURCES DEPARTMENT

300 North Main Street

Versailles, KY 40383

Phone: 859-256-3322/3332

KCTCS is an equal opportunity employer

and education institution.

08/09

DEFINITION OF

SEXUAL HARASSMENT

Sexual Harassment not only violates KCTCS policy, but also violates Title VII of the Civil

Rights Act of 1964, Title IX of the Educational Amendment of 1972 and the Civil Rights Act of 1991. Sexual :!6!--<%"&)$-)*%0"%*)!-)3"5%+/,<%)and unwanted verbal or physical conduct of a sexual nature:

=) 5:%6%)-3;<$--$,")&,)&:$-)conduct is made an explicit or implicit term or condition of an individual’s employment;

=) 5:%6%)-3;<$--$,"),6)6%>%/&$,"),. )such conduct is used as the basis for making employment decisions affecting the individual; or

=) 5:$/:):!-)&:%)8368,-%),6)%..%/&)of substantially altering the effect of or interfering with the individual’s work performance or which creates an intimidating, hostile or offensive workplace environment.

EXAMPLES OF

SEXUAL HARASSMENT

Sexual harassment can take many forms and the determination of what is sexual harassment will vary

according to the particular circumstance. Sexual harassment may involve behavior by a person of either sex against a person of the same or opposite sex.

Examples of sexual harassment may include:

= Conditioning an employment related action (such as hiring, promotion, salary increase or performance appraisal) on a sexual favor or relationship;

= Making or threatening reprisals after a negative response to sexual advances;

= Offensive sexual jokes, comments or sexual overtures;

= Pressure or demand for sexual activity;

= Offensive or unwanted physical contact, inappropriate touching, patting, pinching, kissing, brushing against another’s body;

= Inappropriate or offensive comments about an individual’s body;

= Visual displays of suggestive, erotic or degrading sexually-oriented images or messages in any medium including e-mail or internet web-sites

COMPLAINT

PROCEDURES

What to do if you have experienced or witnessed

sexual harassment

Employees who believe they are victims of, or witnesses to, sexual harassment are urged

to report such incidents as soon as possible. Such behaviors should be immediately reported through one of the following channels:

=) ?,36)",6<!+)-38%6@$-,6')/:!""%+-

=) ?,36)+,/!+):3<!")6%-,36/%-),6)equal employment opportunity coordinator

=) A:%)BCAC2):3<!")6%-,36/%-)department located in Versailles, KY (859) 256-3322/3332

=) A:6,34:)&:%)BCAC2)C,<8+!$"&)Resolution Procedure or other grievance procedure that applies to you

Appropriate investigation and disciplinary action will be taken. No adverse employment action will be taken against employees making a good faith report of alleged harassment.

KCTCS Human Resources Department

HR112

Kentucky Community & Technical College System

Revised 09/2009 Human Resources Policy 3.3.2 and HR Procedure #1

Nepotism Disclosure Form

Please check as appropriate:

I am related by blood or marriage, which includes parents and children, husbands and wives, brothers and sisters, brothers-and sisters-in-law, mothers-and fathers-in-laws, sons-and daughters-in law, uncles, aunts, nieces, nephews, and step-relatives in the same relationships, to the below listed individual(s) who is/are also employee(s) of:

(Employing College and work location; or KCTCS System Office

Name of Relative Relationship Department/work location

I am not currently related by blood or marriage, which includes parents and children, husbands and wives, brothers and sisters, brothers-and sisters-in-law, mothers-and fathers-in-laws, sons-and daughters-in law, uncles, aunts, nieces, nephews, and step-relatives in the same relationships, to any other employee of:

(Employing College and work location; or KCTCS System Office

I acknowledge the information I have provided is accurate to the best of my knowledge. In the event a relationship by blood or marriage, as defined above, is created or modified at a future point, I shall report this change within 15 working days of its creation to the college Human Resources Department. I understand that failure to disclose relationships upon request is grounds for discipline or dismissal. Applicant/Employee Name (Print)

Date

Applicant/Employee Signature

HR105

Kentucky Community & Technical College System

Revised 09/2009 Human Resources Policy 3.3.6

Employee Acknowledgement of Receipt of the Workers’ Compensation Guide to Possible Biohazards in the Workplace

In the event of a suspected exposure the procedure relating to Workers’ Compensation is as follows:

• Employee shall notify his or her supervisor immediately.

• Employer shall notify the local law enforcement agency by calling 911.

• 911 responders will arrange for the testing of the substance at the state public health laboratory or other authorized facility.

• If the substance-screening test is negative, the employee shall be notified that he or she will not

be tested at this time. The public health laboratory will conduct further and more extensive testing to confirm the initial test.

• If the second on the substance is positive, contracting the initial negative test, the employee shall

then be tested and/or treated immediately.

• If either test on the substance is positive, the employee’s supervisor shall complete a First Report of Injury (IA-1) as soon as possible.

• Claims shall not be approved under Workers’ Compensation if an employee independently seeks

testing or medical treatment without a positive substance reading.

I, have been informed by my supervisor of the procedures regarding (please print name) possible exposure to infectious, biological, or harmful chemicals.

Supervisor’s Name

Employee’s Name

Date Employee ID

College Date

For ALL New Hires and All Part-time Employees

1) I am retired from the Kentucky Teachers Retirement System (KTRS).Yes No

2.) If Yes to #1 please indicate the position and location you last worked before retiring.

____________________________ FORMER POSITION TITLE

__________________ _____________________________ Retirement Date SCHOOL AT RETIREMENT

KCTCS provides salary information to the Kentucky Teachers’ Retirement System (KTRS) on its employees who are active or retired members of KTRS. KTRS retirees from the public schools or technical colleges working in part-time positions are limited to teaching 12 teaching hours per fiscal year, or 100 days in a non-teaching position per fiscal year (July 1 through June 30). Any day over 3.5 hours worked is considered a full day, under 3.5 hours is considered a half day. Part-time employees must pay Medicare and FICA taxes.

3.) I am aware of the availability of a voluntary, unmatched 403(b) and 457(b) retirement plans, which allow for regular employees to tax defer part of their salary for retirement. If I choose to participate at this time, it is my responsibility to contact the Human Resources office at my college.

Eligibility You are eligible to participate in the Kentucky Community and Technical College System Voluntary Plans if

You are a regular full-time employee, regular half-time employee, or regular part-time employee.

You are an employee with a temporary full-time, temporary half-time, or temporarypart-time assignment.

______________________________ Please Print Name

Signature

DATE

SSN #

HR 125

August 2016

Kentucky Community and Technical College System

Employment Disclosure - Patient Protection and Affordable Care Act Eligibility

Name: ______________________________________________________________________

Have you been employed by KCTCS in the past 6 months?

☐ No

☐ Yes

If you checked yes, please complete the following information:

KCTCS Employee ID # ______________________________________________________

Birthdate (used to verify KCTCS ID #): ________________________________________

Start Date of Employment: _________________________________________________

End Date of Employment: _____________________ ☐ Currently employed

Where are/were you employed (ex. Fire Commission, Bluegrass CTC, System Office):

________________________________________________________________________

Was your employment ☐ Regular Full-Time

☐ Regular Part-Time

☐ Temporary Full-Time

☐ Temporary Part-Time

During your previous employment were you offered health insurance?

☐ Yes

☐ No

Are you a KCTCS, KERS or KTRS retiree?

☐ Yes

☐ No

Signature ____________________________________________ Date______________________

NOTICE: New Health Insurance Marketplace Coverage Options

and Your Health Coverage

PART A: General Information When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance: the Health Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic information about the new Marketplace and employment-based health coverage offered by your employer.

What is the Health Insurance Marketplace? The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace? You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace? Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer does not offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you (and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you

may be eligible for a tax credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer, then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution - as well as your employee contribution to employer-offered coverage - is often excluded from income for Federal and State income tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information? For more information about your coverage offered by your employer, please check your summary plan description or contact your agency’s/employer’s Insurance Coordinator or Human Resource Generalist. Or, you may contact the Member Services Brach of the Department of Employee Insurance at 888-581-8834 or 502-564-6534.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no

less than 60 percent of such costs.

NOTE: The employer must deliver Part A of the Notice to all employees, regardless of part-time or full-time status and regardless of whether the employee is covered under the employer's health plan. Employers are NOT required to provide a separate notice to dependents or other individuals who are or may become eligible for coverage under the plan but who are not employees. Part B of this Notice is optional and can be delivered to employees together with Part A, or the employer can complete Part B upon request by the employee.

PART B: Information About Health Coverage Offered by Your Employer

This section contains information about health coverage through the Kentucky Employees’ Health Plan offered by your

employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this

information. This information is numbered to correspond to the Marketplace application. If you are an employee who is

seeking coverage through the Marketplace, please request your employer’s information below from your Insurance

Coordinator or your agency’s Human Resource Generalist.

3. Employer name 4. Employer Identification Number (EIN)

5. Employer address 6. Employer phone number

7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address

Here is some basic information about health coverage offered by this employer:

• As your employer, we offer a health plan to:

All employees.

Some employees. Eligible employees are:

o Any person, including an elected public official, who is regularly employed by any department, office,

board, agency or branch of state government; or by a public postsecondary educational institution; or by

any city, urban-county, charter county, county, or consolidated local government, whose legislative body

has opted to participate in the state-sponsored health insurance program pursuant to KRS 79.080; and

who is either a contributing member to any one (1) of the retirement systems administered by the state,

including but not limited to the Kentucky Retirement Systems, Kentucky Teachers’ Retirement System, the

Legislators’ Retirement Plan, or the Judicial Retirement Plan; or is receiving a contractual contribution

from the state toward a retirement plan; or, in the case of a public postsecondary education institution, is

an individual participating in an optional retirement plan authorized by KRS 161.567;

o Any certified or classified employee of a local board of education;

o Any elected member of a local board of education;

o Any person who is a present or future recipient of a retirement allowance from the Kentucky Retirement

Systems, Kentucky Teachers’ Retirement System, the Legislators’ Retirement Plan, the Judicial Retirement

Plan, or the Kentucky Community and Technical College System’s optional retirement plan authorized by

KRS 161.567, except that a person who is receiving a retirement allowance and who is age sixty-five (65)

or older shall not be included, with the exception of persons covered under KRS 61.702(4)(c), unless he or

she is actively employed pursuant to the first bullet above; and

o Any person who meets the eligibility requirements of the employer which are:

[Employer must add any employer-specific eligibility requirements];

OR

o In accordance with the Affordable Care Act, all full-time employees. Full-time employees, as defined by

the ACA, means employees with 30 hours of service per week or 130 hours of service per month.

Employers may impose a less restrictive definition of full-time employees for the purposes of determining

eligibility for health insurance coverage. See employer-specific eligibility requirements above.

• With respect to dependents:

We do offer coverage. Eligible dependents under a KEHP plan include:

o Spouse – a person of the opposite sex to whom you are legally married.

o Common Law Spouse – a person of the opposite sex with whom you have established a Common Law

union in a state which recognizes Common Law marriage (Kentucky does not recognize Common Law

Marriage).

o Child Age 0-18 – in the case of a child who has not yet attained his/her 19th

birthday, “child means an

individual who is:

A son, daughter, stepson, or stepdaughter of the employee/retiree, or

An eligible foster child of the employee/retiree (eligible foster child means an individual who is

placed with the employee/retiree by an authorized placement agency or by judgment, decree, or

other order of any court of competent jurisdiction), or

An adopted child of the employee/retiree (a legally adopted individual of the employee/retiree,

or an individual who is lawfully placed with the employee/retiree for legal adoption by the

employee/retiree, shall be treated as a child), or

o Child Age 19-25 – in the case of a child who has attained his/her 19th

birthday but who has not yet

attained his/her 26th

birthday, “child” means an individual who is a son, daughter, stepson, stepdaughter,

eligible foster child, or an adopted child, and

o Disabled dependent – a dependent child who is totally and permanently disabled may be an eligible

dependent beyond the end of the month in which he/she turns 26, provided the disability (a) started

before his/her 26th

birthday and (b) is medically-certified by a physician to be disabled. A dependent child

will be considered totally and permanently disable if, in the judgment of KEHP, the written certification

adequately demonstrates that the dependent child is unable to engage in any substantial gainful activity

by reason of medically determinable physical or mental impairment that can be expected to result in

death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

We do not offer coverage.

If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be

affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount

through the Marketplace. The Marketplace will use your household income, along with other factors, to determine

whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps

you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you

have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's the

employer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower your

monthly premiums.

The information below corresponds to the Marketplace Employer Coverage Tool. Completing this section is optional for

employers, but will help ensure employees understand their coverage choices.

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the

next 3 months?

Yes (Continue)

13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is

the employee eligible for coverage? (mm/dd/yyyy) (Continue)

No (STOP and return this form to employee)

14. Does the employer offer a health plan that meets the minimum value standard*? Yes (Go to question 15) No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don't include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn't receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don't know,

STOP and return form to employee.

16. What change will the employer make for the new plan year?

Employer won't offer health coverage

Employer will start offering health coverage to employees or change the premium for the lowest-cost plan

available only to the employee that meets the minimum value standard.* (Premium should reflect the

discount for wellness programs. See question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often? Weekly Every 2 weeks Twice a month Monthly Quarterly Yearly

Date of change (mm/dd/yyyy):

An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is no

less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

Special Announcement: New OSHA Regulations Attention All BCTC Faculty and Staff! With new OSHA regulations, we have been notified by KCTCS System Office that all BCTC employees must complete Hazardous Communications (HazCom) training. For most employees this is a one-time endeavor; but for those using potentially hazardous materials (i.e. maintenance and operations staff, laboratory workers, workers in technical programs where hazardous materials may be used), this is an annual requirement. This is a short on-line training with two modules and a quiz at the end. It is estimated to take 20 minutes per module, but most likely will take much less. Please have this required training completed within your first 30 days of employment. Go to http://www.kctcsbest.com/EHS-Classroom.html, click on your respective job area on the right of the screen to take you to the required training. To log in, use your KCTCS e-mail address and bctc2016 for the password. If you have any problems, please contact cindy.mcdonald@kctcs.edu

Form W-4 (2017)

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

Exemption from withholding. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2017 expires February 15, 2018. See Pub. 505, Tax Withholding and Estimated Tax.

Note: If another person can claim you as a dependent on his or her tax return, you can’t claim exemption from withholding if your total income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An 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 don’t apply to supplemental wages greater than $1,000,000.

Basic instructions. If you aren’t exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, 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 claim head of household filing 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. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.

Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, 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 a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.

Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2017. 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.)

A Enter “1” for yourself if no one else can claim you as a dependent . . . . . . . . . . . . . . . . . . A

B Enter “1” if: { • You’re single and have only one job; or

• You’re married, have only one job, and your spouse doesn’t work; or

• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

. . . B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)

G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you

have two to four eligible children or less “2” if you have five or more eligible children.

• If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child. G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) ▶ H

{ • If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions

For accuracy, complete all

worksheets that apply.

and Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.

• If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4 Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate ▶ Whether you are entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

2017 1 Your first name and middle initial Last name 2 Your social security number

Home address (number and street or rural route) 3 Single Married Married, but withhold at higher Single rate.

Note: If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.

City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card,

check here. You must call 1-800-772-1213 for a replacement card. ▶

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2)

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . .

5 6 $

7 I claim exemption from withholding for 2017, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.

If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . ▶ 7 Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.

Employee’s signature

(This form is not valid unless you sign it.) ▶ Date ▶

8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2017)

}

}

Form W-4 (2017) Page 2

Deductions and Adjustments Worksheet Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.

1 Enter an estimate of your 2017 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes, medical expenses in excess of 10% of your income, and miscellaneous deductions. For 2017, you may have to reduce your itemized deductions if your income is over $313,800 and you’re married filing jointly or you’re a qualifying widow(er); $287,650 if you’re head of household; $261,500 if you’re single, not head of household and not a qualifying widow(er); or $156,900 if you’re married filing separately. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $12,700 if married filing jointly or qualifying widow(er)

$9,350 if head of household

$6,350 if single or married filing separately

. . . . . . . . . . .

2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 3 $

4 Enter an estimate of your 2017 adjustments to income and any additional standard deduction (see Pub. 505) 4 $

5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2017 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $

6 Enter an estimate of your 2017 nonwage income (such as dividends or interest) . . . . . . . . 6 $

7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $

8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 8 9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

10

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 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1 2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if

you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more

than “3” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 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 Enter the number from line 2 of this worksheet . . . . . . . . . . 4 5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5 6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $

8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $

9 Divide line 8 by the number of pay periods remaining in 2017. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2017. Enter

the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck

9

$

Married Filing Jointly

Table 1 All Others

Married Filing Jointly

Table 2 All Others

If wages from LOWEST

paying job are—

Enter on

line 2 above

If wages from LOWEST

paying job are—

Enter on

line 2 above

If wages from HIGHEST

paying job are—

Enter on

line 7 above

If wages from HIGHEST

paying job are—

Enter on

line 7 above

$0 - $7,000 0 7,001 - 14,000 1

14,001 - 22,000 2 22,001 - 27,000 3 27,001 - 35,000 4 35,001 - 44,000 5 44,001 - 55,000 6 55,001 - 65,000 7 65,001 - 75,000 8 75,001 - 80,000 9 80,001 - 95,000 10 95,001 - 115,000 11

115,001 - 130,000 12 130,001 - 140,000 13 140,001 - 150,000 14 150,001 and over 15

$0 - $8,000 0 8,001 - 16,000 1

16,001 - 26,000 2 26,001 - 34,000 3 34,001 - 44,000 4 44,001 - 70,000 5 70,001 - 85,000 6 85,001 - 110,000 7

110,001 - 125,000 8 125,001 - 140,000 9 140,001 and over 10

$0 - $75,000 $610 75,001 - 135,000 1,010

135,001 - 205,000 1,130 205,001 - 360,000 1,340 360,001 - 405,000 1,420 405,001 and over 1,600

$0 - $38,000 $610 38,001 - 85,000 1,010 85,001 - 185,000 1,130

185,001 - 400,000 1,340 400,001 and over 1,600

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to

carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.

Revenue Form K-442A804 (11-13)

KENTUCKY DEPARTMENT OF REVENUEEMPLOYEE’S WITHHOLDING EXEMPTION CERTIFICATE Payroll No. __________________________

Print Full Name ________________________________________________________________________ Social Security No. ___________________________

Print Home Address ____________________________________________________________________________________________________________________

HOW TO CLAIM YOUR WITHHOLDING EXEMPTIONS

1. If SINGLE, and you claim an exemption, enter “1,” if you do not, enter “0” .............................................................. ________2. If MARRIED, one exemption each for you and spouse if not claimed on another certificate.

(a) If you claim both of these exemptions, enter “2” (b) If you claim one of these exemptions, enter “1” ................................................................................................ ________ (c) If you claim neither of these exemptions, enter “0”3. Exemptions for age and blindness (applicable only to you and your spouse but not to dependents): (a) If you or your spouse will be 65 years of age or older at the end of the year, and you claim this exemption, enter “4”; if both will be 65 or older, and you claim both of these exemptions, enter “8”.................................. ________ (b) If you or your spouse are blind, and you claim this exemption, enter “4”; if both are blind, and you claim both of these exemptions, enter “8” ......................................................................................................................... ________4. If you claim exemptions for one or more dependents, enter the number of such exemptions ................................ ________5. National Guard exemption (see instruction 1) ............................................................................................................... ________6. Exemptions for Excess Itemized Deductions (Form K-4A) ............................................................................................ ________

7. Add the number of exemptions which you have claimed above and enter the total .................................................8. Additional withholding per pay period under agreement with employer. See instruction 1 ..........................$ _____________

I certify that the number of withholding exemptions claimed on this certificate does not exceed the number to which I am entitled.

Date _________________________________ Signed___________________________________________________________________________________

}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.

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.

www.revenue.ky.gov

FORM PR95

/ Revised 7/1/2007 /

KCTCS

Authorization Agreement for Direct Deposit

KCTCS requires mandatory direct deposit of

payroll checks and reimbursements for

employees. Employee payments will be directly

deposited in the personal bank account(s) you

specify.

Payroll proceeds will be distributed to all

accounts indicated below. Due to the nature of

reimbursements, they will be deposited to the

account listed below with the highest percentage.

If only one account is listed below all proceeds

will be deposited to this account.

Direct deposit service is available to financial

institutions that are members of the National

Automated Clearing House Association

(NACHA). Your bank or credit union should be

able to verify their membership in the NACHA.

Setting up direct deposit takes only three simple

steps:

1. Complete the authorization agreement listed

below.

2. ATTACH A VOIDED CHECK FOR

ALL ACCOUNTS YOU SELECT.

3. Forward this agreement to your local payroll

department representative.

Employee Name _______________________________ Employee ID Number _________________

Action (check one) New Enrollment ____ Change in Accounts _____ Stop Direct Deposit _____

Additional account/add to existing accounts _________

Direct Deposit # 1 Bank Name/Address ___________________________________________________

Routing Number ____________________________ Account Number _____________________________

Savings ___or Checking ____(check one) Percent of pay ______ OR Dollar amount __________

Action (check one) New Enrollment ____ Change in Accounts _____ Stop Direct Deposit _____

Additional account/add to existing accounts _________

Direct Deposit # 2 Bank Name/Address ___________________________________________________

Routing Number ____________________________ Account Number _____________________________

Savings ___or Checking ____(check one) Percent of pay ______ OR Dollar amount ______

I hereby authorize KCTCS to deposit my net pay and/or reimbursement of expenses to my account(s)at the financial

institution(s) indicated above. I also authorize withdrawal transactions from my account in the event of an

overpayment or erroneous deposit.

_____________________________________ ________________

Employee Signature Required Date

FOR ADDITIONAL ACCOUNTS PLEASE USE AN ADDITIONAL FORM

PLEASE READ THE DIRECTIONS ON HOW TO COMPLETE THE DIRECT DEPOSIT FORM