substitute information packet - schoolwires · step 1: apply online step 2: print and completes new...

SUBSTITUTE INFORMATION PACKET

Read and complete each page carefully as each page contains critical information needed for the hiring

process For dates use mmddyyyy For phone numbers please include the area code

Once the packet is complete call the Substitute Services Office for an appointment

Bring the entire completed packet with you to the appointment along with your drivers license social security

card official SEALED transcript or high school diploma or GED and the Direct Deposit Form filled out by your

bank or with a VOIDED check attached to the form

NOTE You must complete the on line application to be considered for employment

PACKET CONTENTS

NEW HIRE PROCESS INFORMATION

ACCEPTANCE LETIER

INFORMATION AND CONSENT TO PERFORM DRUG TEST

DPS CCH VERIFICATION

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK

STATEMENT OF UNDERSTANDING

TEXAS EDUCATION AGENCY ETHNICITY AND RACE DATA QUESTIONAIRE

LETIER OF REASONABLE ASSURANCE

RECEIPT OF EMPLOYEE HANDBOOK FORM

ELECTRONIC COMMUNICATIONS FORM

ECISD DIRECT DEPOSIT FORM

W-4 FORM

FORM 1-9

FICA ALTERNATIVE INFORMATION

OBSERVATION FORM

1

bull au~- - - - shyHIRING PROCESS

Step 1 Apply Online

Step 2 Print and Completes New Hire Packet

Step 3 Attend Paperwork Appointment

Applicants drivers license and social security card will be copied and the 1-9 Form will be completed

The hiring packet will be reviewed and collected

Step 4 Background Check and Fingerprinting

The applicants background check will be submitted to the ECISD Police Department

The applicants information will be uploaded to the State Board of Educator Certification to verify prior

submission of fingerprints to SBEC If fingerprint record is not found a Fast Pass will be generated and sent to

the applicant via emai l with instructions on how to complete the fingerprinting process The applicant is

responsible for paying the fingerprinting fee The fee will not exceed $5020 and must be paid by credit card

at the time of service

Step 5 Orientation

Step 6 Drug Test

After orientation applicants will pick up a drug test form from the HR office on the first floor It will be timeshy

stamped and the applicant wil l have 2 hours from that t ime to complete the drug test The applicant will

receive the address to the lab that conducts the drug tests The lab will send the result of the test to the HR

office ECISD will pay the drug test fee

Step 7 Online Training

Once the drug test resu lts are received in the HR office applicants will be uploaded in SafeSchools and will

receive an email with the login instructions Applicants must complete all online courses and contact the

Substitute Services Office upon completion to make an appointment to complete the Employment Packet

Step 8 Employment Packet

Applicants will sign the Sexual Harassment Form Pre-Employment Affidavit and have their employee badge made

2

- - - - -EC f s D

succaad

ACKNOWLEDGEMENT

I acknowledge that on ______ Mrs Banda Ector County ISD HR Director

offered me the position of

D Substitute Teacher

D Substitute AideClerk

with the Ector County Independent School District for the current school year This offer is

contingent upon my meeting the requirements set by the state and the school district

These requirements include

Passing a mandatory criminal background check

Passing a mandatory drug test

Fingerprints on file with TEA

Completion of all assigned tasks

I accept the offer with Ector County ISD

Date _______Signature -------------- shy

3

Inspire - -~~~-1

i

Dear Applicant

Ector County Independent School District Board Policy DHE (Local) requires all prospective employees to submit a urine sample for detection of drugs The District appreciates your cooperation and compliance with this policy

You have been given directions to the clinic where your urine sample will be collected The clinic is responsible for administering the necessary Chain of Custody paperwork for your sample The Chain of Custody ensures the integrity of your sample from collection to disposal and is accomplished for your protection as well as the Districts Please bear with the clinic as the paperwork is somewhat tedious and time consuming We hope that your association with Ector County Independent School District will be enjoyable and fulfilling

Sincerely

Executive Director of Human Resources

4

------

Subst itutePart-Time

Paraprofessional

Elementary

Secondary

Professional

Dodie Trickett

~

Name ____________Social Security Number ---------shy

DRUG TEST REQUIRED NON-DOT SPLIT SPECIMEN

BREATH ALCOHOL TEST REQUIRED___YES__NO

REASON FOR TEST___Pre- Employment _ _ __Return to Duty

___Follow-up Reasonable Cause

Post-Accident

This is to authorize the above named individual to take a test for Ector County ISO This authorization is only good for the date shown above

(Signature of authorized personal)

NOTE Employer copy of Chain of Custody form and Billing for this test should be sent to Ector County ISD attn Estela Vejil at address listed above I understand that according to ECISD Board Policy DHE (Local) I am required to submit a urine sample for detection of drugs I consent freely and voluntarily to this request for urine sample and will provide it when requested In addition I consent freely and voluntarily to the disclosure of the test results to Ector County ISO its agents officers and employees authorized to receive those results I understand that a refusal to provide the urine sample for drug testing process will disqualify me from employment I understand that a urine sample which tests positive for the presence of drugs will also disqualify me from employment with the district

Signature of applicantemployee Date

5

DPS Computerized Criminal History (CCH) Verification

(AGENCY COPY)

I acknowledge that a Computerized Criminal APPLICANT or EMPLOYEE NAME (Please print)

History (CCH) check will be performed by accessing the Texas Department of Public Safety Secure

Website and will be based on name and DOB identifiers I supply (This is not a consent form) Authority

for this agency to access an individualrsquos criminal history data may be found in Texas Government Code

411 Subchapter F

Name-based information is not an exact search and only fingerprint record searches represent

true identification to criminal history therefore the organization conducting the criminal history check is

not allowed to discuss with me any criminal history record information obtained using this method The

agency may request that I have a fingerprint search performed to clear any misidentification based on

the result of the name and DOB search Once this process is completed the information on my

fingerprint criminal history record may be discussed with me

In order to complete the process I must make an appointment with the Fingerprint Applicant

Services of Texas (FAST) as instructed online at wwwtxdpsstatetxus Crime RecordsReview of

Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080 submit a full and

complete set of fingerprints request a copy be sent to the agency listed below and pay a fee of $2495 to

the fingerprinting services company

(This copy must remain on file by your agency Required for future DPS Audits)

___________________________________ Signature of Applicant or Employee

Date

HUMAN RESOURCES DEPARTMENT Agency Name (Please print)

NOEMI CHAVEZ Agency Representative Name (Please print)

___________________________________ Signature of Agency Representative

2019 Date

Rev 092013

Please Check and Initial each Applicable Space

CCH Report Printed YES NO initial Purpose of CCH Empl VolContractor initial Date Printed

initial Destroyed Date initial

Retain in your files

r-- ~------- -_ --~ - middotI p

r middot i shy ~

f - lt

middot middot~1

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH THE FCRA (FAIR CREDIT REPORTING ACT)

Last Name First Name Middle Name

Maiden andor Other Names used

Present Street Address Telephone Number (include area code)

City State Zip Code County

Date of Birth0 Social Security Number Sex Race0

I am an applicant for employment with Ector County Independent School District and have been advised that as part of the application process the employer conducts a criminal history background check I do hereby consent to the employers use of any information provided during the application process in performing the criminal history check

The employer has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment In addition I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the employer Under the Fair Credit Reporting Act I have been advised that upon request I will be provided the name address and telephone number of the reporting agency as well as the nature substance and source of all information

AS SHOWN ON THE ORIGINALAPPLICATON TO BE USED ONLY FOR CRIMINAL HISTORY SEARCHES AND NOT PART OF THE PERSONNEL FILE

Continued on the next page )

of2

7

The following are my responses to questions about my criminal record history (if any) with explanations to any questions with a YES answer Please click YES or NO

1 Have you ever been convicted of or charged with a felony or misdemeanor or received probation or deferred adjudication YES NO If YES please provide an explanation below

2 Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States YES NO If YES please provide an explanation below

3 As of the date of this authorization do you have any pending criminal charges against you 0YES0NO If YES please provide an explanation below

HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE CORRECT AND COMPLETE I UNDERSTAND THAT IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE THAT GOUNDS FOR THE CANCELING OF ANY AND ALL OFFERS OF EMPLOYMENT WILL EXIST AND MAY BE USED AT THE DISCRETION OF THE EMPLOYER

Signed this day of_ _ _ ______________ 20_____ (Day of the month) (Month) (Year)

APPLICANT (Print Name) ----------------- - ------ shy

APPLICANTS SIGNATURE ------------------------~

Page 2 of 2

8

--- ------

middotshy

E C t S D - - - - -__


Substitute teachers are employed on a daily basis for regularly scheduled school days and are

called upon as needed Newly hired substitute teachers are reasonably assured of

employment throughout the current school year By virtue of this assurance please

understand that you are not eligible of unemployment compensation benefits during any

school breaks including but not limited to summer break intersessions Thanksgiving break

winter break and spring break This assurance is contingent upon continued school

operations and will not apply in the event of any disruption that is beyond the control of the

district (ie lack of school funding natural disasters court orders public insurrections war

etc

I UNDERSTAND THE ABOVE STATEMENT AND AGREE TO THE PROVISIONS THEREOF

Signature --- ----------- Date

Witness -------------~

9

Exhibit 1A Texas Education Agency

Texas Public School StudentStaff Ethnicity and Race Data Questionnaire

The United States Department of Education (USDE) requires all state and local education institutions to collect data on ethnicity and race for students and staff This information is used for state and federal accountability reporting as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC)

School district staff and parents or guardians of students enrolling in school are requested to provide this information If you decline to provide this information please be aware that the USDE requires school districts to use observer identification as a last resort for collecting the data for federal reporting

Please answer both parts of the following questions on the students or staff members ethnicity and race United States Federal Register (71 FR 44866)

part 1 Ethnjcjty Is the person HispanicLatino (Choose only one)

D HispanicLatino -A person of Cuban Mexican Puerto Rican South or Central American or other Spanish culture or origin regardless of race

D Not HispanicLatino

part 2 Race What is the persons race (Choose one or more)

D American Indian or Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America) and who maintains a tribal affiliation or community attachment

D Asian -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

D Black or African American - A person having origins in any of the black racial groups of Africa

D Native Hawaiian or Other Pacific Islander - A person having origins in any of the original peoples of Hawaii Guam Samoa or other Pacific Islands

D White - A person having origins in any of the original peoples of Europe the Middle East or North Africa

Staff Name (please print) Staff Signature

Staff Identification Number Date

This space reserved for Local school observer- upon completion and entering data in student software system file this form in students permanent folder Ethnicity- choose only one Race - choose one or more

- American Indian or Alaska Native __Hispanic I Latino --Asian

__ Black or African American __Not HispanicLatino __Native Hawaiian or Other Pacific Islander

--White

Observer signature Campus and Date

L-_ ____________T_exa==-sEducation Agency shy March 201 O

10

------------

-~~ --shy -

c ECTOR COUNTY INDEPENDENT SCHOOL DISTRICT

LETTER OF REASONABLE ASSURANCE 2018-2019

Dear _ ____ __

This letter provides notice of reasonable assurance ofcontinued employment with the district when each school term resumes after a scheduled school break By virtue of this notice please understand that you may not be eligible for unemployment insurance benefits drawn on school district wages during any scheduled school breaks including but not limited to the summer winter and spring breaks This assurance is contingent upon continued school operations and will not apply in the event of any disruption that is beyond the control of the district (eg lack of school funding natural disasters court orders public insurrections war etc)

Nothing contained herein constitutes an employment contract Your continued employment is on an atshywill basis At-will employers may terminate employees at any given time for any reason or for no reason except for legally impermissible reasons At-will employees are free to resign at any time for any reason or for no reason During my employment I agree to comply with the rules regulations and policies of the Ector County Independent School District

Your services on behalf of the children of ECISD are appreciated and we hope that you will be able to continue your association with the district

Please verify andor complete the information listed below acknowledge this document by selecting middotacknowledge If any of the below listed information needs to be updated please contact Human Resources Failure to acknowledge this letter of reasonable assurance by will be treated as a voluntary resignation By acknowledging this document I agree to comply with the rules regulations and policies of the Ector County Independent School District

Name Employee Number ---------------~

Address - - ---shy - --shy City ST ZIP----shy - - ---shy---shy

Phone --------------~

ECISD Employee Signature Date

Sincerely Date

Dr Gregory C Nelson

11

Employee Handbook Receipt

CampusDepartment-----------shy

I hereby acknowledge receipt of a copy of the Ector County ISD Employee Handbook I agree to read the handbook and abide by the standards policies and procedures defined or referenced in this document

Employees have the option of receiving the handbook in electronic format or hard copy

The ECSD Employee Handbook may be viewed at the Districts website

httpwwwectorcountyisdorgPage930

The information in this handbook is subject to change I understand that changes in district policies may supersede modify or render obsolete the information summarized in this book As the district provides updated policy information I accept responsibility for reading and abiding by the changes

I understand that no modifications to contractual relationships or alterations of at-will employment relationships are intended by this handbook

I understand that I have an obligation to inform my supervisor or department head of any changes in personal information such as phone number address etc I also accept responsibility for contacting my supervisor or Technology Services if I have questions or concerns or need further explanation

Signature Date

ECISD Employee Handbook 2018-2019 12

EMPLOYEE AGREEMENT FOR ACCEPTABLE USE OF THE ELECTRONIC COMMUNICATIONS SYSTEM You are being given access to the Districts technology resources Through this system you will be able to communicate with other schools colleges organizations and people around the world through the Internet and other technology resourcesnetworks You will have access to hundreds of databases libraries and computer services all over the world With this opportunity comes responsibility It is important that you read the District policy administrative regulations and agreement form and ask questions if you need help in understanding them Inappropriate system use will result in suspension or revocation of the privilege of using this educational and administrative tool Please note that the Internet is a network of many types of communication and information networks It is possible that you may run across some material you might find objectionable While the District will use filtering technology to restrict access to such material it is not possible to absolutely prevent such access It will be your responsibility to follow the rules for appropriate use

RULES FOR APPROPRIATE USE

middot The account is to be used mainly for educational purposes but limited personal use is

permitted

middot You will be held responsible at all times for the proper use of your account and the District

may suspend or revoke your access if you violate the rules

middot Remember that people who receive e-mail from you with a school address might think your

message represents the schools point of view

INAPPROPRIATE USES

Using the system for any illegal purpose

Disabling bypassing or attempting to disable any Internet filtering device

Encrypting communications to avoid security review

Borrowing someone elses account without permission

Pretending to be someone else when transmitting or receiving messages

Using inappropriate language such as swear words vulgarity ethnic or racial slurs and

any other inflammatory language

middot Downloading or using copyrighted information without permission from the copyright

holder

middot Intentionally introducing a virus to the computer system

middot Transmitting or accessing materials that is abusive obscene sexually oriented

threatening harassing damaging to anothers reputation or illegal

middot Transmitting pictures without obtaining prior permission from all individuals depicted

or from parents or depicted individuals who are under the age of 18

middot Posting messages or accessing materials that are abusive obscene sexually

oriented threatening harassing damaging to anothers reputation or illegal

13

-----------------

middot Wasting school resources through improper use of the computer system including

sending chain letters

Gaining unauthorized access to restricted information or resources

Using personal internet connections for students or direct instruction

CONSEQUENCES FOR INAPPROPRIATE USE

Suspension of access to the system

Revocation of the computer system account or

Other disciplinary or legal action in accordance with the District policies and

applicable laws

The employee agreement must be renewed each academic year

I understand that my computer use is not private and that ECSD may monitor my activity on the

computer system at any time

I have read ECISDs Electronic Communications System Policy CQ (LOCAL) and CQ (Regulations)

and agree to abide by their provisions I understand that the policy can be located on the ECISD

website at

httppoltasborgHomelndex421

In consideration of the privilege of using the districts electronic communications system and in

consideration for having access to the public networks I hereby release ECISD its operators

and any institutions with which they are affiliated from any and all claims and damages of any

nature arising from my use of or inability to use the system including without limitation the

type of damages identified in the districts policy and administrative regulations including the

transfer of files between home and district workstations

Print full Name------------shy

Signature --------------~

Date

Employee ID ________

Campus 998- Substitute Services

ECISD Employee Handbook

14

ECTOR COUNTY INDEPENDENT SCHOOL DISTRICT AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT

PO Box 39 12 802 N Sam Houston Ave Odessa Texas 79760 Phone (432) 456-9769 Fax (432) 456-9768

Emp ovee I ~n ormat10n Name (Last) (First) (Middle)

Social Security Employee

CampusDepartment Home Telephone

Position Full-timePart-timeSubst itute

I authorize ECISD to credit my account with the depository names on this form IfECISD erroneously deposits funds into my account I authorize ECJSD to initiate the necessary debit entries not to exceed the tota l of the original amount credited for the cunent pay period This authorization will remain in effect until ECJSD has received written notification from me that it is to be terminated in such time and manner from ECTSD to act o n it

I understand if my check is sent to the wrong bank or account because incorrect information was submitted by me or if my account is closed or has changed and I fa il to notify ECISD in time to act on this information it may take several days to make any corrections

ALL ECISD employees are eligible to open an account at West Texas Educators Credit Union Departments with hiring authority must make this requirement known during the interviewing process

SIGNATURE DATE

Attach a voided check OR have your financial institution complete the information below Financial Institution Transit Code Account _ _ Checking _ _ Savings

Name of Financial Institution

Mai ling Address ofFinancial Institution City Sta1 e Zip Code

Signature ofAuthorized Officer Date Signed

Name ofOfficer (Print or Type) Title Telephone No

Please open the W-4 file on the left in attachements and fill out and print Revised 03212011

15

Form W-4 (2019) Future developments For the latest information about any future developments related to Form W-4 such as legislation enacted after it was published go to wwwirsgovFormW4

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 You may claim exemption from withholding for 2019 if both of the following apply

bull For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability and

bull For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability

If youre exempt complete only lines 1 2 3 4 and 7 and sign the form to validate it Your exemption for 2019 expires February 17 2020 See Pub 505 Tax Withholding and Estimated Tax to learn more about whether you qualify for exemption from withholding

General Instructions If you arent exempt follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld For regular wages withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages

You can also use the calculator at wwwirsgovW4App to determine your tax withholding more accurately Consider

using this calculator if you have a more complicated tax situation such as if you have a working spouse more than one job or a large amount of nonwage income not subject to withholding outside of your job After your Form W-4 takes effect you can also use this calculator to see how the amount of tax you re having withheld compares to your projected total tax for 2019 If you use the calculator you dont need to complete any of the worksheets for Form W-4

Note that if you have too much tax withheld you will receive a refund when you fi le your tax return If you have too little tax w ithheld you will owe tax when you file your tax return and you might owe a penalty

Filers with multiple jobs or working spouses If you have more than one job at a time or if youre married filing jointly and your spouse is also working read all of the instructions including the instructions for the Two-EarnersMultiple Jobs Worksheet before beginning

Nonwage income If you have a large amount of nonwage income not subject t o withholding such as interest or dividends consider making estimated tax payments using Form 1040-ES Estimated Tax for Individuals Otherwise you might owe additional tax Or you can use the Deductions Adjustments and Additional Income Worksheet on page 3 or the calculator at wwwirsgovW4App to make sure you have enough tax withheld from your paycheck If you have pension or annuity income see Pub 505 or use the calculator at wwwirsgovW4App to find out if you should adjust your withholding on Form W-4 or W-4P

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

Specific Instructions Personal Allowances Worksheet Complete this worksheet on page 3 first to determine the number of withholding allowances to c laim

Line C Head of household please note Generally you may claim head of household filing status on your tax return only if youre unmarried and pay more than 50 of the costs of keeping up a home for yourself and a qualifying individual See Pub 501 for more informat ion about filing status

Line E Child tax credit When you file your tax return you may be eligible to claim a child tax credit for each of your eligible children To qualify the child must be under age 17 as of December 31 must be your dependent who lives with you for more than half the year and must have a valid social security number To learn more about this credit see Pub 972 Child Tax Credit To reduce the tax withheld from your pay by taking this credit into account follow the instructions on line E of the worksheet On the worksheet you wi ll be asked about your total income For this purpose total income includes all of your wages and other income including income earned by a spouse if you are filing a joint return

Line F Credit for other dependents When you file your tax return you may be eligible to claim a credit for other dependents for whom a child tax credit can t be claimed such as a qualifying child who doesnt meet the age or social security number requirement for the child tax credit or a qualifying relative To learn more about t his credit see Pub 972 To reduce the tax withheld from your pay by taking this credit into account follow the instructions on line F of the worksheet On the worksheet you will be asked about your total income For this purpose total

----------------------------- Separate here and give Form W-4 to your employer Keep the worksheet(s) for your records ----------------------------shy

Form W-4 Department of the TreasuryInternal Revenue Service

Employees Withholding Allowance Certificate ~Whether youre 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

OMS No 1545-0074

~19 1 Your first name and middle initial ILast name 12 Your social security number

Home address (number and street or rural route) 3 Osingle 0Married D Married but withhold at higher Single rate Note If married filing separately check Married but withhold at higher Single rate

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 800-772-1213 for a replacement card 0

5 Total number of allowances youre claiming (from the applicable worksheet on the following pages) 5 6 Additional amount if any you want withheld from each paycheck 6 $ 7 I claim exemption from w ithholding for 2019 and I certify t hat I meet both of the following conditions for exempt ion

bull Last year I had a right to a refund of all federal income tax withheld because I had no tax liabi lity and

bull This year I expect a refund of all federal income tax withheld because I expect to have no tax liabil ity If you meet both conditions write Exempt here I 7 1

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 Employees signature (This form is not valid unless you sign it) bull Date~

8 Employers name and address (Employer Complete boxes 8 and 10 if sending to IRS and complete boxes 8 9 and 10 if sending to State Directory of New Hires)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice see page 4 Cat No 102200 Form W-4 (2019)

16

Form W-4 (2019) Page 2

income includes all of your wages and other income including income earned by a spouse if you are filing a joint return Line G Other credits You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits such as tax credits for education (see Pub 970) If you do so your paycheck will be larger but the amount of any refund that you receive when you file your tax return will be smaller Follow the instructions for Worksheet 1-6 in Pub 505 if you want to reduce your withholding to take these credits into account Enter -0- on lines E and F if you use Worksheet 1-6

Deductions Adjustments and Additional Income Worksheet Complete this worksheet to determine if youre able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income such as IRA contributions If you do so your refund at the end of the year will be smaller but your paycheck will be larger Youre not required to complete this worksheet or reduce your withholding if you dont wish to do so

You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding such as interest or dividends

Another option is to take these items into account and make your withholding more accurate by using the calculator at wwwirsgovW4App If you use the calculator you dont need to complete any of the worksheets for Form W-4

Two-EarnersMultiple Jobs Worksheet Complete this worksheet if you have more than one job at a time or are married fi ling jointly and have a working spouse If you

dont complete this worksheet you might have too little tax withheld If so you will owe tax when you file your tax return and might be subject to a penalty

Figure the total number of allowances youre entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4 Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs For example if you earn $60000 per year and your spouse earns $20000 you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4 and your spouse should enter zero (-0-) on lines 5 and 6 of his or her Form W-4 See Pub 505 for details

Another option is to use the calculator at wwwirsgovW4App to make your withholding more accurate

Tip If you have a working spouse and your incomes are similar you can check the Married but withhold at higher Single rate box instead of using this worksheet If you choose this option then each spouse should fi ll out the Personal Allowances Worksheet and check the Married but withhold at higher Single rate box on Form W-4 but only one spouse should claim any allowances for credits or fi ll out the Deductions Adjustments and Additional Income Worksheet

Instructions for Employer Employees do not complete box 8 9 or 10 Your employer will complete these boxes if necessary

New hire reporting Employers are required by law to report new employees to a designated State Directory of New Hires Employers may use Form W-4 boxes 8 9

and 1 0 to comply with the new hire reporting req uirement for a newly hired employee A newly hired employee is an employee who hasnt previously been employed by t he employer or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4 For information and links to each designated State Directory of New Hires (including for US territories) go to wwwacfhhsgovcssemployers

If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee complete boxes 8 9 and 10 as follows

Box 8 Enter the employers name and address If the employer is sending a copy of this form to a State Directory of New Hires enter the address where child support agencies should send income withholding orders

Box 9 If the employer is sending a copy of this form to a State Directory of New Hires enter the employees first date of employment which is the date services for payment were first performed by t he employee If the employer rehired the employee after the employee had been separated from the employers service for at least 60 days enter the rehire date

Box 10 Enter the employers employer identification number (EIN)

17

---

---

---

------

------

C


Personal Allowances Worksheet (Keep for your records) A Enter 1 for yourself B Enter 1 if you will file as married filing jointly

Enter 1 if you will file as head of household

bull Youre single or married filing separately and have only one job or ) D Enter 1 if bull Youre married filing jointly have only one job and your spouse doesnt work or

( bullYour wages from a second job or your spouses wages (or the total of both) are $1500 or less

E Child tax credit See Pub 972 Child Tax Credit for more information bull If your total income will be less than $71201 ($103351 if married fi ling jointly) enter 4 for each eligible child bull If your total income will be from $71201 to $179050 ($103351 to $345850 if married filing jointly) enter 2 for each eligible child

bull If your total income will be from $179051 to $200000 ($345851 to $400000 if married filing jointly) enter 1 for each eligible child

bull If your total income will be higher than $200000 ($400000 if married filing jointly) enter -0-

F Credit for other dependents See Pub 972 Child Tax Credit for more information

bull If your total income will be less than $71201 ($103351 if married filing jointly) enter 1 for each eligible dependent

bull If your total income will be from $71201 to $179050 ($103351 to $345850 if married filing jointly) enter 1 for every two dependents (for example -0- for one dependent 1 if you have two or three dependents and 2 if you have four dependents)

bull If your total income will be higher than $179050 ($345850 if married filing jointly) enter -0- G Other credits If you have other credits see Worksheet 1-6 of Pub 505 and enter the amount from that worksheet

here If you use Worksheet 1-6 enter -0- on lines E and F

H Add lines A through G and enter the total here ~

A B -- shyc

D

E ___

F

G

H

For accuracy complete all worksheets that apply

bull If you plan to itemize or claim adjustments to income and want to reduce your withholding or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding see the Deductions Adjustments and Additional Income Worksheet below

bull If you have more than one job at a time or are married filing jointly and you and your spouse both work and the combined earnings from all jobs exceed $53000 ($24450 if married filing jointly) see the Two-EarnersMultiple Jobs Worksheet on page 4 to avoid having too little tax withheld

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

Deductions Adjustments and Additional Income Worksheet Note Use this worksheet only if you plan to itemize deductions claim certain adjustments to income or have a large amount of nonwage

income not subject to withholding

1 Enter an estimate of your 2019 itemized deductions These include qualifying home mortgage interest charitable contributions state and local taxes (up to $10000) and medical expenses in excess of 10 of your income See Pub 505 for details

$24400 if youre married filing jointly or qualifying widow(er) ) 2 Enter $18350 if youre head of household (

$12200 if youre single or married filing separately 3 Subtract line 2 from line 1 If zero or less enter -0-

4 Enter an estimate of your 2019 adjustments to income qualified business income deduction and any additional standard deduction for age or blindness (see Pub 505 for information about these items)

5 Add lines 3 and 4 and enter the total 6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) 7 Subtract line 6 from line 5 If zero enter -0- If less than zero enter the amount in parentheses 8 Divide the amount on line 7 by $4200 and enter the result here If a negative amount enter in parentheses

Drop any fraction

9 Enter the number from the Personal Allowances Worksheet line H above 10 Add lines 8 and 9 and enter the total here If zero or less enter -0- If you plan to use the Two-Earners

Multiple Jobs Worksheet also enter this total on line 1 of that worksheet on page 4 Otherwise stop here and enter this total on Form W-4 line 5 page 1

1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18


Two-EarnersMultiple Jobs Worksheet Note Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here

1 Enter the number from the Personal Allowances Worksheet line H page 3 (or if you used the Deductions Adjustments and Additional Income Worksheet on page 3 the number from line 10 of that worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here However if youre married filing jointly and wages from the highest paying job are $75000 or less and the combined wages for you and your spouse are $107000 or less dont 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 t his worksheet 5 6 Subtract line 5 from line 4 6 7 Find the amount in Table 2 below t hat 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 2019 For example divide by 18 if youre paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2019 Enter the result here and on Form W-4 line 6 page 1 This is the additional amount to be withheld from each paycheck

Table 1 Married Filing Jointly

If wages from LOWEST Enter on paying job are- line 2 above

$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others

If wages from LOWEST paying job areshy

$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over

Enter on line 2 above

0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $

Table 2 Married Filing Jointly All Others

If wages from HIGHEST paying job areshy

$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over

Enter on If wages from HIGHEST Enter on line 7 above paying job are- line 7 above

$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540

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 al lowances providing fraudulent information may subject you to penalties Routine uses of this information include giving it to the Department of Justice for civi l and criminal litigation to

cities states the District of Columbia and US 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 arent required to provide the information requested on a form thats 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 cont ents may become mat erial 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 t he 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 instruct ions for your income tax return

19

Employment Eligibility Verification USCIS Form 1-9Department of Homeland Security

OMB I 0 161 5-0047 US Citizenship and Immigration Services Expires 08312019

~START HERE Read instructions carefully before completing this form The Instructions must be available either in paper or electronically

during completion of th is form Employers are liable for errors in the completion of this form

ANTI-DISCRIMINATION NOTICE It is illegal to discriminate against work-authorized individuals Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination

Section 1 Employee Information and Attestation (Employees must complete and sign Section 1 of Form 1-9 no later than the first day ofemployment but not before accepting a job offer)

Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

Address (Street Number and Name) Apt Number City or Town State ZIP Code

Date of Birth (mmddlYWY) US Social Security Number

ITIJ-rn-1 I I I I Employees E-mail Address Employees Telephone Number

I am aware that federal law provides for imprisonment andor fines for false statements or use of false documents in connection with the completion of this form

I attest under penalty of perjury that I am (check one of the following boxes)

0 1 A citizen of the United States

0 2 A noncitizen national of the United States (See instructions)

0 3 A lawful permanent resident Alien Registration NumberUSCIS Number)

0 4 An alien authorized to work until (expiration date if applicable mmddyyyy)

Some aliens may write NA in the expiration date field (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9 QR Code - Section 1

An Alien Registration NumberUSCIS Number OR Form 1-94 Admission Number OR Foreign Passport Number Do Not Write In This Space

1 Alien Registration NumberUSCIS Number

OR 2 Form 1-94 Admission Number

OR 3 Foreign Passport Number

Country of Issuance

Signature of Employee Todays Date (mmddlyyyy)

Preparer andor Translator Certification (check one) 0 I did not use a preparer or translator 0 A preparer(s) andor translator(s) assisted the employee in completing Section 1

(Fields below must be completed and signed when preparers andor translators assist an employee in completing Section 1)

I attest under penalty of perjury that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct Signature of Preparer or Translator ITodays Date (mmddlYWY)

Last Name (Family Name) First Name (Given Name)

Address (Street Number and Name) City or Town State ZIP Code

Employer Completes Next Page

Form 1-9 07117117 N

LISTS OF ACCEPTABLE DOCUMENTS All documents must be UNEXPIRED

Employees may present one selection from List A or a combination of one selection from List B and one selection from List C

LIST A LIST B LISTC

Documents that Establish Both Identity and

Employment Authorization OR

Documents that Establish Identity

AND

Documents that Establish Employment Authorization

1 US Passport or US Passport Card 1 Drivers license or ID card issued by a 1 State or outlying possession of the

2 Permanent Resident Card or Alien United States provided it contains a

Registration Receipt Card (Form 1-551) photograph or information such as name date of birth gender height eye

3 Foreign passport that contains a color and address temporary 1-551 stamp or temporary 1-551 printed notation on a machineshy 2 ID card issued by federal state or local readable immigrant visa government agencies or entities

provided it contains a photograph or 4 Employment Authorization Document 2 Certification of report of birth issued information such as name date of birth

that contains a photograph (Form by the Department of State (Forms gender height eye color and address 1-766) DS-1350 FS-545 FS-240)

3 School ID card with a photograph 5 For a nonimmigrant alien authorized 3 Original or certified copy of birth

to work for a specific employer certificate issued by a State because of his or her status

4 Voters registration card county municipal authority or

5 US Military card or draft record territory of the United States a Foreign passport and bearing an official seal 6 Military dependents ID card b Form 1-94 or Form l-94A that has

the following 4 Native American tribal document 7 US Coast Guard Merchant Mariner Card(1) The same name as the passport 5 US Citizen ID Card (Form 1-197)

and 8 Native American tribal document

6 Identification Card for Use of(2) An endorsement of the aliens nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form

6 Passport from the Federated States of

A Social Security Account Number card unless the card includes one of the following restrictions

(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH OHS AUTHORIZATION

Resident Citizen in the United 9 Drivers license issued by a Canadian States (Form 1-179) government authority

7 Employment authorization For persons under age 18 who are document issued by the unable to present a document Department of Homeland Security listed above

10 School record or report card Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form 11 Clinic doctor or hospital record 1-94 or Form 1-94A indicating nonimmigrant admission under the 12 Day-care or nursery school record Compact of Free Association Between the United States and the FSM or RMI

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-27 4)

Refer to the instructions for more information about acceptable receipts

Fonn I-9 0717 17 Page 3 of3

900 S Capital of Texas Hwy Suite 350 Austin TX 78746 TCG Phone 5127958999 Fax 5127950414

ADMINISTRATORS Toll Free 8009439179 Fax 8889899247 Email 457tcgservicescom ----~

457(8) FICA ALTERNATIVE PLAN AND TRUST

WHAT IS A 457(b) FICA ALTERNATIVE

The Omnibus Budget

Reconci liation Act of 1990

(OBRA 90) mandates that

employees of public

agencies including school

d istricts who are not

members of the employers

existing retirement system as of January 1 1992 be

covered under Social Security or a qualifying alternate plan

The ESC Region 10 457(b)

FICA Alternative Plan satisfies

federal requirements and

provides substantial cost savings compared to Social

Security

BENEFITS OF CONTRIBUTING TO A 457(b) FICA ALTERNATIVE PLAN

bull Bridge your retirement income gap

bull Lower your taxes

bull Automatic saving Payroll deducted

FICAAlt 7 201 7

IMPORTANT POINTS ABOUT YOUR 457(b) FICA ALTERNATIVE

Eligibility An employee is requ ired to pa rticipate in the FICA Alternative Plan if they

meet one of the e ligibility requi rements listed below

bull Part-time (20 hours or less per week)

bull Seasonal (f ive months or less per year)

bull Temporary (contract of two years or less in duration)

bull Not covered by TRS in a position otherwise covered by TRS

Contributions Social Security requires that the eq uiva lent of 124 of an employees

salary be contributed each month (62 employee 62 employer) However the FICA

Alternative Plan requires only a 75 contribution to a retirement account The deferra ls

are made on a pretax basis unlike Social Security which are made on an after-tax

basis

Investments The portfolio selection is designated by the employer The options are as

follows

FICA Diversified Portfolio-The Diversified Portfolio is directly overseen by the Region

10 RAMS Investment Advisory Committee The portfolio is comprised of a broad

range of equity and bond mutual funds as well as individual bonds typically held to

maturity and is periodically changed to adapt to changing market conditions

FICA Government Income Portfolio-All investment instruments issued by andor

backed by the US Government

Distributions The employee or their beneficiary wi ll receive the FICA Alternative Plan

account balance when an employee becomes el ig ible for a distribution for any of the

fo llowing reasons

Termination of Employment Death

Permanent and Total Disability Retirement

bull Changed employment status to a position covered by another retirement system

(eg TRS)

If there have been no contributions to the account for two (2) years and the account

balance is less than $5000 the employee may be able to request a distribution

Taxation When the employee begins to receive benefits the funds received become

taxable income If the taxable portion of the account balance exceeds $200 the

employee can avoid immediate taxation by directing the account balance to

A traditional IRA

An eligib le employer plan that accepts the rollover (ie TRS 403(b) 457 etc)

(cont on back)

-----I TCG

ADMINISTRATORS _____~


MORE IMPORTANT POINTS ABOUT YOUR 457(b) FICA ALTERNATIVE

Designating a Beneficiary If the employee dies while a participant in the Plan the account balance will be distributed to the

employees beneficiary If the employee is married at the time of death the spouse is automatically the beneficiary If the

employee wishes to designate someone other than the spouse as beneficiary the emp loyee must do so in writing and the spouse

must sign a spousal consent form If the employee is unmarried at the time of death the account ba lance will be paid to the

employees estate unless another beneficiary has been designated To designate a beneficiary p lease login to your account at

wwwregion1 Oramsorg using the inst ructions under Account Access below

Company Offering Services The Company chosen to provide the 457(b) FICA Alternative Plan is TCG Admin istrators a company

with many years of proven expertise in administering retirement p lans t o public sector employees

Protection from Liability The District as a 457(b) plan sponsor is responsible for the types of investments offered to participants

Most 457(b) plans do not protect the District from fiduciary liability The ESC Region 10 457(b) FICA Alternative Retirement Plan

offers fiduciary protection for the District through an Investment Advisory Agreement with TCG Investment Advisory Services LP

Fees TCG Administrators receives 115 of the plan assets and $50 per participant per month paid by the participant TCG

Advisors receives 35 of assets as the investment advisory fee Region 10 receives $10 per participant per month (normally

deducted from participant accounts) as its fee for running the RAMS program and the individual investments have fees that vary

by t ype of investment The investment fees are shown on the Region 10 RAMS website at wwwregion 1 Oramsorg

Account Access To review your account balance or request a distribution you can access your account on the Region 10 RAMS

website at wwwregion 1 Oramsorg Please follow the steps below to access your account on line

1 Click the green Login box in the upper right-hand corner

2 Click the yellow Retirement Login box

3 User Name will be your Social Security Number (no spaces or dashes)

4 Password will be your date of birth (MMDDYYYY)

900 S Capital of Texas Hwy Suite 350

Austin TX 78746 Phone 5127958999 Fax 5127950414

Toll Free 8009439179 Fax 8889899247

Email 457tc9servicescom

------------

CLASSROOM OBSERVATION RECORD

ECTOR COUNTY INDEPENDENT SCHOOL DISTRICT SUBSTITUTE TEACHER

SUBSTITUTE APPLICANT -------shy

PLEASE CALL THE CAMPUSES TO SCHEDULE APPOINTMENTS FOR OBSERVATION IF YOU CALL A

SECONDARY CAMPUS KNOW WHAT SUBJECT AREA YOU WISH TO OBSERVE BEFORE YOU CALL

COMPLETE 6 HOURS OF CLASSROOM OBERVATION BE SURE THE PRINCIPAL SIGNS AND DATES

THE FORM

DATEOBSERVATION OBSERVATION SIGNATURE OF

PRINCIPALTIMELOCATION

SIGNATURE OF APPLICANT

bull au~- - - - shyHIRING PROCESS

Step 1 Apply Online

Step 2 Print and Completes New Hire Packet

Step 3 Attend Paperwork Appointment

Applicants drivers license and social security card will be copied and the 1-9 Form will be completed

The hiring packet will be reviewed and collected

Step 4 Background Check and Fingerprinting

The applicants background check will be submitted to the ECISD Police Department

The applicants information will be uploaded to the State Board of Educator Certification to verify prior

submission of fingerprints to SBEC If fingerprint record is not found a Fast Pass will be generated and sent to

the applicant via emai l with instructions on how to complete the fingerprinting process The applicant is

responsible for paying the fingerprinting fee The fee will not exceed $5020 and must be paid by credit card

at the time of service

Step 5 Orientation

Step 6 Drug Test

After orientation applicants will pick up a drug test form from the HR office on the first floor It will be timeshy

stamped and the applicant wil l have 2 hours from that t ime to complete the drug test The applicant will

receive the address to the lab that conducts the drug tests The lab will send the result of the test to the HR

office ECISD will pay the drug test fee

Step 7 Online Training

Once the drug test resu lts are received in the HR office applicants will be uploaded in SafeSchools and will

receive an email with the login instructions Applicants must complete all online courses and contact the

Substitute Services Office upon completion to make an appointment to complete the Employment Packet

Step 8 Employment Packet

Applicants will sign the Sexual Harassment Form Pre-Employment Affidavit and have their employee badge made

2

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3

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Sincerely


4

------


Paraprofessional

Elementary

Secondary

Professional

Dodie Trickett

~






Post-Accident





5


(AGENCY COPY)





411 Subchapter F














Date




2019 Date

Rev 092013





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$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




- - - - -EC f s D

succaad

ACKNOWLEDGEMENT














3

Inspire - -~~~-1

i

Dear Applicant



Sincerely


4

------


Paraprofessional

Elementary

Secondary

Professional

Dodie Trickett

~






Post-Accident





5


(AGENCY COPY)





411 Subchapter F














Date




2019 Date

Rev 092013





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Dr Gregory C Nelson

11










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permitted





INAPPROPRIATE USES









holder








13

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applicable laws






website at









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Date




14










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OMS No 1545-0074












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$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




Inspire - -~~~-1

i

Dear Applicant



Sincerely


4

------


Paraprofessional

Elementary

Secondary

Professional

Dodie Trickett

~






Post-Accident





5


(AGENCY COPY)





411 Subchapter F














Date




2019 Date

Rev 092013





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11










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13

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website at









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$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




------


Paraprofessional

Elementary

Secondary

Professional

Dodie Trickett

~






Post-Accident





5


(AGENCY COPY)





411 Subchapter F














Date




2019 Date

Rev 092013





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13

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website at









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Date




14










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OMS No 1545-0074












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$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM





(AGENCY COPY)





411 Subchapter F














Date




2019 Date

Rev 092013





r-- ~------- -_ --~ - middotI p

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Page 1 of2

7









Page 2 of 2

8

--- ------

middotshy

E C t S D - - - - -__










etc



Witness -------------~

9




















--White



10

------------

-~~ --shy -



Dear _ ____ __







Phone --------------~


Sincerely Date

Dr Gregory C Nelson

11










Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

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F

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Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




r-- ~------- -_ --~ - middotI p

r middot i shy ~

f - lt

middot middot~1











Page 1 of2

7









Page 2 of 2

8

--- ------

middotshy

E C t S D - - - - -__










etc



Witness -------------~

9




















--White



10

------------

-~~ --shy -



Dear _ ____ __







Phone --------------~


Sincerely Date

Dr Gregory C Nelson

11










Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

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A B -- shyc

D

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F

G

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Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM












Page 2 of 2

8

--- ------

middotshy

E C t S D - - - - -__










etc



Witness -------------~

9




















--White



10

------------

-~~ --shy -



Dear _ ____ __







Phone --------------~


Sincerely Date

Dr Gregory C Nelson

11










Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




--- ------

middotshy

E C t S D - - - - -__










etc



Witness -------------~

9




















--White



10

------------

-~~ --shy -



Dear _ ____ __







Phone --------------~


Sincerely Date

Dr Gregory C Nelson

11










Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM























--White



10

------------

-~~ --shy -



Dear _ ____ __







Phone --------------~


Sincerely Date

Dr Gregory C Nelson

11










Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

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F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




------------

-~~ --shy -



Dear _ ____ __







Phone --------------~


Sincerely Date

Dr Gregory C Nelson

11










Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM













Signature Date





permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM







permitted





INAPPROPRIATE USES









holder








13

-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




-----------------









applicable laws






website at









Signature --------------~

Date




14










SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM













SIGNATURE DATE







15





















OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM
























OMS No 1545-0074












16


















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM





















17

---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




---

---

---

------

------

C















A B -- shyc

D

E ___

F

G

H












Drop any fraction



1 $------- shy

2 $

3 _$___ _

4 $ 5 --$___ _

6 ____$ _

7 _$____

8 9

10

18











$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM














$0 - $5000 0 5001 - 9500 1 9501 - 19500 2

19501 - 35000 3 35001 - 40000 4 40001 - 46000 5 46001 - 55000 6 55001 - 60000 7 60001 - 70000 8 70001 - 75000 9 75001 - 85000 10 85001 - 95000 11 95001 - 125000 12

125001 - 155000 13 155001 - 165000 14 165001 - 175000 15 175001 - 180000 16 180001 - 195000 17 195001 - 205000 18 205001 and over 19

All Others


$0 - $7000 7001 - 13000

13001 - 27500 27501 - 32000 32001 - 40000 40001 - 60000 60001 - 75000 75001 - 85000 85001 - 95000 95001 - 100000

100001 - 110000 110001 - 115000 115001 - 125000 125001 - 135000 135001 - 145000 145001 - 160000 160001 - 180000 180001 and over


0 1 2 3 4 5 6 7 8 9

10 11 12 13 14 15 16 17

9 $



$0 - $24900 24901 - 84450 84451 - 173900

173901 - 326950 326951 - 413700 413701 - 617850 617 851 and over


$420 $0 - $7200 $420 7201 - 36975500 500

910 36976 - 81700 910 1000 81 701 - 158225 1000 1330 158226 - 201600 1330 1450 201601 - 507800 1450 1540 507801 and over 1540







19























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM


























Country of Issuance








Form 1-9 07117117 N



LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM






LIST A LIST B LISTC




AND






























The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM








The Omnibus Budget



employees of public










Security





FICAAlt 7 201 7












basis


follows









fo llowing reasons




(eg TRS)






A traditional IRA


(cont on back)

-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




-----I TCG



























Toll Free 8009439179 Fax 8889899247


------------







THE FORM




------------







THE FORM


