t e d n u a d w u g p e i l h e o b n q g c b a l · form i-9 10/21/2019 page 2 of 3 uscis form i-9...

46

Upload: others

Post on 04-Nov-2020

0 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � ! � " # $ � % # ! � & � � ' ( ! &) * + , - . * / - / 0 * 1 - . * 2 * 3 4 5 , * 6 7 3 - 8 3 9 . : 1 2 7 ; < = > ? ? @ A B C D ? E E C A F G ? @ H D G F D H I ? J ? K L ? M ? E N @ EA C G O B ? H ? E I ? P C J ? Q C F A N @ I ? R L @ J ? A ? L K L @ R O N Q G ? @ H P C J D ? J K L A ? D O J C K L E ? E H C N @ S T U A F D H C G ? J V W N @ Q C PH > ? ? @ A B C D ? E P C J G D J ? X F L J ? Q C F J L @ P C J G N H L C @ N @ E D L R @ N H F J ? N @ E H > ? D L R @ N H F J ? C P H > ? A F D H C G ? J Q C F M N @ HH C M C J Y P C J V = > ? D ? P C J G D G F D H I ? A C G O B ? H ? E L @ H > ? L J ? @ H L J ? H Q N @ E J ? H F J @ ? E H C Q C F J Z [ \ ] ^ _ ` a b \ c ^ d e c f g h^ i i j d ` V k P H > ? l F D H C G ? J L D L @ N W N @ N R ? E l N J ? m J R N @ L n N H L C @ o W l m p q H > ? D ? E C A F G ? @ H D M L B B D H L B B I ? H F J @ ? EL @ H C H > ? Z [ \ ] ^ _ ` a b \ c ^ d e c f g h ^ i i j d ` Vr � � � � � s � t u � v � � w � � � x � � � � u t � � � � � yz V = > ? S T U l F D H C G ? J Q C F M N @ H H C M C J Y P C J M L B B I ? @ C H L P L ? E C P Q C F J C P P L A L N B D H N J H E N H ? V{ V | T N @ H J N } k ~ M L B B I ? R L K ? @ H C Q C F P C J F D ? L @ S T U � D � B ? A H J C @ L A � L D L H � ? J L P L A N H L C @ T Q D H ? G o � � � p V� V � C F M L B B J ? A ? L K ? N A C O Q C P N � ? @ E C J | F H > C J L n N H L C @ P C J T ? J K L A ? D N @ E l F D H C G ? J T ? J K L A ? U B N @ V� � � � � � � � - � � * 8 5 � � - 3 � 5 � 8 � - 3 / 0 * � � 6 / - . * 3 � * � - 3 * 9 + + / 0 * 9 � - 4 * 6 5 / � 9 / 5 - � 6 - , , � 3 � � - � 3 5 6 � � - � �� 9 � . * � / � - 3 6 * 3 4 5 , * 6 �� � � � t � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � t � � � � � � � t � � � � � � � � �� 0 * 6 * � - , � . * � / 6 . � 6 / � * , - . � + * / * � � 6 5 8 � * � 9 � � 6 � � . 5 / / * � / - / 0 * + - , 9 +� � 2 - � � 5 , * �   � 3 5 * � 6 � . . 9 3 � - � / 0 * 6 * � - , � . * � / 6 5 6 + - , 9 / * � - � � 9 8 * ¡ �l C O Q C P N A F J J ? @ H U > C H C k ~ k ¢ £ ¤ ¤ ¥ { z z { ¦ k U T H N @ E N J E Dl C O Q C P T C A L N B T ? A F J L H Q l N J E k ¢ £ ¤ ¤ ¥ z £ z � ¦ U J C K L E ? J | R J ? ? G ? @ H§ C J G k ¥ ¨ ¦ � G O B C Q G ? @ H � B L R L I L B L H Q k ¢ £ ¤ ¤ ¥ { { © { ¦ k U U N Q G ? @ H U C B L A L ? Dª ¥ £ ¦ § ? E ? J N B ª L H > > C B E L @ R l ? J H L P L A N H ? k ¢ £ ¤ ¤ ¥ { { « { ¦ ª N L K ? J | R J ? ? G ? @ Hk ¢ ª ¥ £ ¦ T H N H ? ª L H > > C B E L @ R l ? J H L P L A N H ? k ¢ £ ¤ ¤ ¥ { { « � ¦ k W U | l = � @ J C B B G ? @ H� 0 * 6 * � - , � . * � / 6 6 0 - � + � � * � * � / � - 3 5 � � - 3 . 9 / 5 - � 9 + - 3 � � / � 3 * � � 3 � - 6 * 69 � � � - / 6 � � . 5 / / * � / - / 0 * + - , 9 + � � 2 - � � 5 , * �k W U | l = k U § C J G k @ D H J F A H L C @ N B T > ? ? Hk ¢ £ ¤ ¤ ¥ { � ¨ ¨ ¦ ¬ ? O C J H C P k @ ­ F J Q H C N U J C K L E ? J= L G ? D > ? ? H k @ D H J F A H L C @ D® @ E ? J D H N @ E L @ R ª C J Y ª ? ? Y K D U N Q U ? J L C ES T U U J C K L E ? J U N Q J C B B T A > ? E F B ?T N @ H J N } o � � � p l N B B ¬ ? P ? J ? @ A ? ¯ F L E ?l ¥ ¨ © | ¦ ~ L J ? A H ~ ? O C D L H § C J Gk ¢ £ £ £ ¥ ° ¤ ° ° ¦ ~ ? I L H l N J E | O O B L A N H L C @l ~ l l B ? N @ S N @ E D l C F @ H § B Q ? Jm P P L A L N B T � k ® S ? N B H > A N J ? ± J C A > F J ?� � � � t � � � x � � � � � � � � � � � � � � � � � � � � � � � � u t � � � � � � � t � � � � � � � t � � � � � � � � � ²� 0 * 6 * � - , � . * � / 6 . � 6 / � * , - . � + * / * � � 6 5 8 � * � 9 � � 6 � � . 5 / / * � / - / 0 * + - , 9 +� � 2 - � � 5 , * �   � 3 5 * � 6 � . . 9 3 � - � / 0 * 6 * � - , � . * � / 6 5 6 + - , 9 / * � - � � 9 8 * ¡ �l C O Q C P N A F J J ? @ H O > C H C k ~ § C J G k ¥ ¨ ¦ � G O B C Q G ? @ H � B L R L I L B L H Qk ¢ £ ¤ ¤ ¥ { z z { ¦ k U T H N @ E N J E D k ¢ £ ¤ ¤ ¥ { { © { ¦ k U U N Q G ? @ H U C B L A L ? Dk ¢ £ ¤ ¤ ¥ z £ z � ¦ U J C K L E ? J | R J ? ? G ? @ H

Page 2: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � ! � " # $ � % # ! � & � � ' ( ! &� - � � - � 9 7 0 - / - � � ³ W F D H I ? A F J J ? @ H q @ C @ ¥ ? } O L J ? E N @ E L D D F ? E H > J C F R > N ¯ C K ? J @ G ? @ H C J T A > C C B � @ H L H Q Vo � } N G O B ? D L @ A B F E ? ³ ~ J L K ? J � D ¢ L A ? @ D ? q T H N H ? k ~ q U N D D O C J H q W L B L H N J Q k ~ q T A > C C B k ~ q ? H A V p´ * � * 3 9 + 9 � � � µ ) � ¶ ³ = > ? D ? P C J G D N J ? F D ? E I Q H > ? k B B L @ C L D ~ ? O N J H G ? @ H C P ¬ ? K ? @ F ? N @ E H > ? k ¬ T H C A C B B ? A HL @ P C J G N H L C @ N I C F H Q C F J H N } D H N H F D N @ E Q C F J M L H > > C B E L @ R J ? X F ? D H D V = > ? B C A N B C P P L A ? A N @ @ C H > ? B O L @A C G O B ? H L @ R H > ? D ? P C J G D V k P Q C F @ ? ? E > ? B O M L H > H > ? D ? P C J G D q O B ? N D ? A C @ H N A H N H N } A C @ D F B H N @ H V� µ ¶ · · � ¡ ¸ ¸ ¡ ¹ � � � 5 4 5 � � 9 + 7 3 - 4 5 � * 3 2 / 9 � � 9 3 � 6 ³ = > L D P C J G ? D H N I B L D > ? D I N D L A L @ P C J G N H L C @ I ? H M ? ? @ Q C F N @ EQ C F J ? G O B C Q ? J q H > ? S T U l F D H C G ? J V� µ ¶ · · � ¸ ¶ ¸ º ¹ 1 - . * 2 * 3 4 5 , * 6 7 3 - 8 3 9 . 7 3 - 4 5 � * 3   8 3 * * . * � / ³ = > L D P C J G ? D H N I B L D > ? D N R J ? ? G ? @ H D I ? H M ? ? @Q C F N @ E H > ? S T U U J C R J N G N D M ? B B N D M > N H D ? J K L A ? H Q O ? o D p Q C F M L B B I ? O J C K L E L @ R H C H > ? A F D H C G ? J V´ � � » � � ¼ ³ U B ? N D ? A C G O B ? H ? O N R ? z V = > ? l F D H C G ? J M L B B A C G O B ? H ? O N R ? { N P H ? J Q C F > N K ? O J C K L E ? E H > ?l F D H C G ? J M L H > H > ? N A A ? O H N I B ? E C A F G ? @ H D B L D H ? E L @ H > ? L @ D H J F A H L C @ D V | E E L H L C @ N B L @ D H J F A H L C @ D A N @ I ?P C F @ E N H > H H O D ³ ½ ½ M M M V F D A L D V R C K ½ L ¥ ¨ q C J A N @ I ? O J L @ H ? E N H Q C F J B C A N B ~ ¬ T C P P L A ? V� µ ¶ · · � ¡ ¡ ¾ ¡ ¹ � � � 5 4 5 � � 9 + 7 3 - 4 5 � * 3 7 9 � . * � / 7 - + 5 , 5 * 6 ³ = > L D P C J G O J C K L E ? D L G O C J H N @ H O C B L A L ? D q J F B ? D N @ EL @ P C J G N H L C @ A C @ A ? J @ L @ R O N Q G ? @ H D N @ E O C H ? @ H L N B P J N F E L D D F ? D V l F D H C G ? J D L R @ N H F J ? J ? X F L J ? E V� µ ¶ · · � ¡ ¡ ¿ ¡ ¹ ) 9 5 4 * 3 7 3 - 8 3 9 . 7 3 - 4 5 � * 3   8 3 * * . * � / ³ � C F G F D H ? @ J C B B L @ H > ? k B B L @ C L D W ? E L A N L E U J C R J N G| E K N @ A ? E l B C F E = ? A > @ C B C R Q o k W U | l = p D Q D H ? G H C I ? N @ ? B L R L I B ? W ? E L A N L E U J C K L E ? J V� µ ¶ · · � ¡ ¡ ¿ º ¹ � » 7   � � � � � 5 4 5 � � 9 + 7 3 - 4 5 � * 3 � � 3 - + + . * � / ´ - 3 . ³ � C F G F D H ? @ J C B B L @ H > ? k B B L @ C L D W ? E L A N L EU J C R J N G | E K N @ A ? E l B C F E = ? A > @ C B C R Q o k W U | l = p D Q D H ? G H C I ? N @ ? B L R L I B ? W ? E L A N L E U J C K L E ? J V� � ¼ ¾   ¹   � / 0 - 3 5 À 9 / 5 - � � - 3 � * � - 6 5 / - � � * , � 3 3 5 � 8 7 9 � . * � / 6 ³ k P Q C F M C F B E B L Y ? E L J ? A H E ? O C D L H L @ H C N @N A A C F @ H N H N P L @ N @ A L N B L @ D H L H F H L C @ q A C G O B ? H ? H > L D P C J G N @ E J ? H F J @ H C ³~ S T ½ � } O ? @ E L H F J ? | A A C F @ H L @ R ~ ? I L H l N J E U J C ­ ? A H q z ° ° T ¯ J N @ E | K ? � q z Á  § B q T O J L @ R P L ? B E q k ¢ « { à « {� µ ¶ ¶ ¶ � Ä · Ä Ä ¹ � + + 5 � - 5 6 � * � 5 / » 9 6 / * 3 � 9 3 � 7 9 � . * � / � � / 5 - � ´ - 3 . ³ k P Q C F M L D > H C J ? A ? L K ? O N Q G ? @ H H > J C F R >N E ? I L H A N J E q O B ? N D ? A C G O B ? H ? H > L D P C J G N @ E J ? H F J @ H C H > ? N E E J ? D D B L D H ? E C @ H > ? E C A F G ? @ H V� µ ¶ · · � ¡ º ¼ ¼ ¹ � * � - 3 / - � � � Å � 3 � / - 9 � � � � 5 4 5 � � 9 + 7 3 - 4 5 � * 3 ³ ª L H > L @ { £ > C F J D C P N M C J Y ¥ J ? B N H ? E L @ ­ F J Q qO B ? N D ? A C G O B ? H ? H > L D P C J G N @ E J ? H F J @ H C H > ? N E E J ? D D D H N H ? E C @ H > ? E C A F G ? @ H V§ C J G C J ? L @ P C J G N H L C @ C @ S T U q F D ? H > ? ~ S T M ? I D L H ? o > H H O ³ ½ ½ M M M V E > D V D H N H ? V L B V F D p I Q D ? N J A > L @ R H ? J G D B L Y ? ³Æ ~ S T m P P L A ? ¢ C A N H C J Ç q Æ § J ? X F ? @ H B Q | D Y ? E È F ? D H L C @ D Ç q Æ S T U U N Q J C B B T A > ? E F B ? Ç q Æ ¬ ? O C J H § J N F E Ç q Æ ¬ ? O C J H| I F D ? Ç q ? H A V� C F A N @ J ? X F ? D H � G O B C Q G ? @ H � ? J L P L A N H L C @ q ~ F O B L A N H ? ª ¥ { � D É q C J N ¯ J C D D � N J @ L @ R D T H N H ? G ? @ H I Q D ? @ E L @ RQ C F J ¬ ? X F ? D H q § F B B Ê N G ? q T C A L N B T ? A F J L H Q Ë q l F J J ? @ H | E E J ? D D ½ U > C @ ? Ë q T L R @ N H F J ? N @ E ~ N H ? H C ³ § | Ì o { z à p© © à ¥ ¨ £ � £ C J ~ S T ½ ~ ¬ T S T U ¢ N I C J ¬ ? B N H L C @ D q U m ± C } z ¨ £ { ¨ q T O J L @ R P L ? B E q k ¢ « { à ¨ £ ¥ ¨ £ { ¨É k P J ? X F ? D H L @ R N ~ F O B L A N H ? ª ¥ { q N A C O Q C P Q C F J O > C H C k ~ C J J ? A ? @ H G N L B L D J ? X F L J ? E V¬ ? O C J H | I F D ? ½ Ê ? R B ? A H ³ o ¤ ° ° p � « ¤ ¥ z £ « �¯ ? @ ? J N B ~ S T S ? B O B L @ ? ³ o ¤ ° ° p ¤ £ � ¥ « z © £U J C K L E ? J | D D L D H N @ A ? ¢ L @ ? ³ o ¤ ° ° p ¤ ° £ ¥ � ¤ � � C O H {~ ? I L H l N J E ½ ~ L J ? A H ~ ? O C D L H ³ o { z à p à ¤ © ¥ à à ¨ °k B B L @ C L D U J C K L E ? J ~ ? I L H W N D H ? J l N J E ³ o ¤ « « p � � ¤ ¥ { ¨ £ £T � k ® ® @ L C @ ³ o ¤ « « p ¨ � � ¥ à � £ ¤

Page 3: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �! � � � � " � # � � � � � # � � � � $ � � � � � � � � � � � � � % � � � � � � � � � � � � � � �& � � � ! � � � � & � � � � � � � � � � � � � � � � � � � � � � � � ' � � & � � � � � � � �� � & � � � � � � � & � � � � � � � � � � � � � � � � � � � � � � � � ' � � � ( � � � ) # � � � � �* + , - . / 0 1 2 . 0 0 1 3 4 5 , / 3 6 7 8 * 9 : * ; / 3 < / = = 5 , > 3 ? + - 0 / < > + + 1 0 1 3 4 @ A ; 7 . B 4 - C 1 0 D = 5 1 / B 1 B 1 1 4 E 1> 3 B 4 0 . 2 4 > - 3 B - 3 4 E 1 F G H = / ? 1 - + 4 E 1 * 3 < > I > < . / 5 ; 0 - I > < 1 0 : C = 5 - , C 1 3 4 ; / 2 J 1 4 5 1 4 4 1 0 K

Page 4: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 5: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

Page 6: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 7: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)

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

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

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

3. A lawful permanent resident

4. An alien authorized to work until (See instructions)

(expiration date, if applicable, mm/dd/yyyy):

(Alien Registration Number/USCIS Number):

Some aliens may write "N/A" in the expiration date field.

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

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

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

Signature of Employee Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one): I did not use a preparer or translator. A preparer(s) and/or translator(s) assisted the employee in completing Section 1.(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.Signature of Preparer or Translator Today's Date (mm/dd/yyyy)

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

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

Employer Completes Next Page

Page 8: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification (Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Last Name (Family Name) M.I.First Name (Given Name)Employee Info from Section 1

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

Additional Information QR Code - Sections 2 & 3 Do Not Write In This Space

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any) (mm/dd/yyyy)

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States. The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Today's Date (mm/dd/yyyy)Signature of Employer or Authorized Representative Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name) City or Town State ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable)Last Name (Family Name) First Name (Given Name) Middle Initial

B. Date of Rehire (if applicable)Date (mm/dd/yyyy)

Document Title Document Number Expiration Date (if any) (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual. Signature of Employer or Authorized Representative Today's Date (mm/dd/yyyy) Name of Employer or Authorized Representative

Page 9: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

LISTS OF ACCEPTABLE DOCUMENTSAll 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

2. Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

1. U.S. Passport or U.S. Passport Card

3. Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa

4. Employment Authorization Document that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

Documents that Establish Both Identity and

Employment Authorization

6. Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has the following:(1) The same name as the passport;

and(2) An endorsement of the alien's

nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are unable to present a document

listed above:

1. Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

9. Driver's license issued by a Canadian government authority

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

2. ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

7. Employment authorization document issued by the Department of Homeland Security

1. A Social Security Account Number card, unless the card includes one of the following restrictions:

2. Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3. Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4. Native American tribal document

6. Identification Card for Use of Resident Citizen in the United States (Form I-179)

Documents that Establish Employment Authorization

5. U.S. Citizen ID Card (Form I-197)

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 10/21/2019

Examples of many of these documents appear in the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Page 10: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 11: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Form W-42020

Employee’s Withholding Certificate

Department of the Treasury Internal Revenue Service

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Give Form W-4 to your employer.

Your withholding is subject to review by the IRS.

OMB No. 1545-0074

Step 1:

Enter

Personal

Information

(a) First name and middle initial Last name

Address

City or town, state, and ZIP code

(b) Social security number

Does your name match the name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.

(c) Single or Married filing separately

Married filing jointly (or Qualifying widow(er))

Head of household (Check only if you’re unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2:

Multiple Jobs

or Spouse

Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spousealso works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This optionis accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . .

TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)

Step 3:

Claim

Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 $

Multiply the number of other dependents by $500 . . . . $

Add the amounts above and enter the total here . . . . . . . . . . . . . 3 $

Step 4

(optional):

Other

Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expectthis year that won’t have withholding, enter the amount of other income here. This mayinclude interest, dividends, and retirement income . . . . . . . . . . . . 4(a) $

(b) Deductions. If you expect to claim deductions other than the standard deductionand want to reduce your withholding, use the Deductions Worksheet on page 3 andenter the result here . . . . . . . . . . . . . . . . . . . . . 4(b) $

(c) Extra withholding. Enter any additional tax you want withheld each pay period . 4(c) $

Step 5:

Sign

Here

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

Employee’s signature (This form is not valid unless you sign it.) Date

Employers

Only

Employer’s name and address First date of employment

Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2020)

Page 12: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Form W-4 (2020) Page 2

General Instructions

Future Developments

For the latest information about developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.

Purpose of Form

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. If too little is withheld, you will generally owe tax when you file your tax return and may owe a penalty. If too much is withheld, you will generally be due a refund. Complete a new Form W-4 when changes to your personal or financial situation would change the entries on the form. For more information on withholding and when you must furnish a new Form W-4, see Pub. 505.

Exemption from withholding. You may claim exemption from withholding for 2020 if you meet both of the following conditions: you had no federal income tax liability in 2019 and you expect to have no federal income tax liability in 2020. You had no federal income tax liability in 2019 if (1) your total tax on line 16 on your 2019 Form 1040 or 1040-SR is zero (or less than the sum of lines 18a, 18b, and 18c), or (2) you were not required to file a return because your income was below the filing threshold for your correct filing status. If you claim exemption, you will have no income tax withheld from your paycheck and may owe taxes and penalties when you file your 2020 tax return. To claim exemption from withholding, certify that you meet both of the conditions above by writing “Exempt” on Form W-4 in the space below Step 4(c). Then, complete Steps 1(a), 1(b), and 5. Do not complete any other steps. You will need to submit a new Form W-4 by February 16, 2021.

Your privacy. If you prefer to limit information provided in Steps 2 through 4, use the online estimator, which will also increase accuracy.

As an alternative to the estimator: if you have concerns with Step 2(c), you may choose Step 2(b); if you have concerns with Step 4(a), you may enter an additional amount you want withheld per pay period in Step 4(c). If this is the only job in your household, you may instead check the box in Step 2(c), which will increase your withholding and significantly reduce your paycheck (often by thousands of dollars over the year).

When to use the estimator. Consider using the estimator at www.irs.gov/W4App if you:

1. Expect to work only part of the year;

2. Have dividend or capital gain income, or are subject to additional taxes, such as the additional Medicare tax;

3. Have self-employment income (see below); or

4. Prefer the most accurate withholding for multiple job situations.

Self-employment. Generally, you will owe both income and self-employment taxes on any self-employment income you receive separate from the wages you receive as an employee. If you want to pay these taxes through withholding from your wages, use the estimator at www.irs.gov/W4App to figure the amount to have withheld.

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

Specific InstructionsStep 1(c). Check your anticipated filing status. This will determine the standard deduction and tax rates used to compute your withholding.

Step 2. Use this step if you (1) have more than one job at the same time, or (2) are married filing jointly and you and your spouse both work.

Option (a) most accurately calculates the additional tax you need to have withheld, while option (b) does so with a little less accuracy.

If you (and your spouse) have a total of only two jobs, you may instead check the box in option (c). The box must also be checked on the Form W-4 for the other job. If the box is checked, the standard deduction and tax brackets will be cut in half for each job to calculate withholding. This option is roughly accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld, and this extra amount will be larger the greater the difference in pay is between the two jobs.

!CAUTION

Multiple jobs. Complete Steps 3 through 4(b) on only one Form W-4. Withholding will be most accurate if you do this on the Form W-4 for the highest paying job.

Step 3. Step 3 of Form W-4 provides instructions for determining the amount of the child tax credit and the credit for other dependents that you may be able to claim when you file your tax return. To qualify for the child tax credit, the child must be under age 17 as of December 31, must be your dependent who generally lives with you for more than half the year, and must have the required social security number. You may be able to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as an older child or a qualifying relative. For additional eligibility requirements for these credits, see Pub. 972, Child Tax Credit and Credit for Other Dependents. You can also include other tax credits in this step, such as education tax credits and the foreign tax credit. To do so, add an estimate of the amount for the year to your credits for dependents and enter the total amount in Step 3. Including these credits will increase your paycheck and reduce the amount of any refund you may receive when you file your tax return.

Step 4 (optional).

Step 4(a). Enter in this step the total of your other estimated income for the year, if any. You shouldn’t include income from any jobs or self-employment. If you complete Step 4(a), you likely won’t have to make estimated tax payments for that income. If you prefer to pay estimated tax rather than having tax on other income withheld from your paycheck, see Form 1040-ES, Estimated Tax for Individuals.

Step 4(b). Enter in this step the amount from the Deductions Worksheet, line 5, if you expect to claim deductions other than the basic standard deduction on your 2020 tax return and want to reduce your withholding to account for these deductions. This includes both itemized deductions and other deductions such as for student loan interest and IRAs.

Step 4(c). Enter in this step any additional tax you want withheld from your pay each pay period, including any amounts from the Multiple Jobs Worksheet, line 4. Entering an amount here will reduce your paycheck and will either increase your refund or reduce any amount of tax that you owe.

Page 13: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Form W-4 (2020) Page 3

Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.

1

Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have onejob, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the“Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3 . . . . . . . . . . . . . . . . . . . . . 1 $

2 Three jobs. If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.

a

Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying jobin the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a . . . . . . . . . . . . . . . . . . . . . . . 2a $

b

Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2b $

c Add the amounts from lines 2a and 2b and enter the result on line 2c . . . . . . . . . . 2c $

3 Enter the number of pay periods per year for the highest paying job. For example, if that job paysweekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc. . . . . . 3

4

Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter thisamount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additionalamount you want withheld) . . . . . . . . . . . . . . . . . . . . . . . . . 4 $

Step 4(b)—Deductions Worksheet (Keep for your records.)

1

Enter an estimate of your 2020 itemized deductions (from Schedule A (Form 1040 or 1040-SR)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income . . . . . . . 1 $

2 Enter: {• $24,800 if you’re married filing jointly or qualifying widow(er)

• $18,650 if you’re head of household

• $12,400 if you’re single or married filing separately} . . . . . . . . 2 $

3 If line 1 is greater than line 2, subtract line 2 from line 1. If line 2 is greater than line 1, enter “-0-” . . 3 $

4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040 or 1040-SR)). See Pub. 505 for more information 4 $

5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4 . . . . . . . . . . . 5 $

Privacy Act and Paperwork Reduction Act Notice. We ask for the information 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 with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

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

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

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

Page 14: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Form W-4 (2020) Page 4

Married Filing Jointly or Qualifying Widow(er)

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $0 $220 $850 $900 $1,020 $1,020 $1,020 $1,020 $1,020 $1,210 $1,870 $1,870

$10,000 - 19,999 220 1,220 1,900 2,100 2,220 2,220 2,220 2,220 2,410 3,410 4,070 4,070

$20,000 - 29,999 850 1,900 2,730 2,930 3,050 3,050 3,050 3,240 4,240 5,240 5,900 5,900

$30,000 - 39,999 900 2,100 2,930 3,130 3,250 3,250 3,440 4,440 5,440 6,440 7,100 7,100

$40,000 - 49,999 1,020 2,220 3,050 3,250 3,370 3,570 4,570 5,570 6,570 7,570 8,220 8,220

$50,000 - 59,999 1,020 2,220 3,050 3,250 3,570 4,570 5,570 6,570 7,570 8,570 9,220 9,220

$60,000 - 69,999 1,020 2,220 3,050 3,440 4,570 5,570 6,570 7,570 8,570 9,570 10,220 10,220

$70,000 - 79,999 1,020 2,220 3,240 4,440 5,570 6,570 7,570 8,570 9,570 10,570 11,220 11,240

$80,000 - 99,999 1,060 3,260 5,090 6,290 7,420 8,420 9,420 10,420 11,420 12,420 13,260 13,460

$100,000 - 149,999 1,870 4,070 5,900 7,100 8,220 9,320 10,520 11,720 12,920 14,120 14,980 15,180

$150,000 - 239,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,190 16,050 16,250

$240,000 - 259,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 12,790 13,990 15,520 17,170 18,170

$260,000 - 279,999 2,040 4,440 6,470 7,870 9,190 10,390 11,590 13,120 15,120 17,120 18,770 19,770

$280,000 - 299,999 2,040 4,440 6,470 7,870 9,190 10,720 12,720 14,720 16,720 18,720 20,370 21,370

$300,000 - 319,999 2,040 4,440 6,470 8,200 10,320 12,320 14,320 16,320 18,320 20,320 21,970 22,970

$320,000 - 364,999 2,720 5,920 8,750 10,950 13,070 15,070 17,070 19,070 21,290 23,590 25,540 26,840

$365,000 - 524,999 2,970 6,470 9,600 12,100 14,530 16,830 19,130 21,430 23,730 26,030 27,980 29,280

$525,000 and over 3,140 6,840 10,170 12,870 15,500 18,000 20,500 23,000 25,500 28,000 30,150 31,650

Single or Married Filing Separately

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 -

9,999$10,000 -

19,999$20,000 -

29,999$30,000 -

39,999$40,000 -

49,999$50,000 -

59,999$60,000 -

69,999$70,000 -

79,999$80,000 -

89,999$90,000 -

99,999$100,000 -

109,999$110,000 -

120,000

$0 - 9,999 $460 $940 $1,020 $1,020 $1,470 $1,870 $1,870 $1,870 $1,870 $2,040 $2,040 $2,040

$10,000 - 19,999 940 1,530 1,610 2,060 3,060 3,460 3,460 3,460 3,640 3,830 3,830 3,830

$20,000 - 29,999 1,020 1,610 2,130 3,130 4,130 4,540 4,540 4,720 4,920 5,110 5,110 5,110

$30,000 - 39,999 1,020 2,060 3,130 4,130 5,130 5,540 5,720 5,920 6,120 6,310 6,310 6,310

$40,000 - 59,999 1,870 3,460 4,540 5,540 6,690 7,290 7,490 7,690 7,890 8,080 8,080 8,080

$60,000 - 79,999 1,870 3,460 4,690 5,890 7,090 7,690 7,890 8,090 8,290 8,480 9,260 10,060

$80,000 - 99,999 2,020 3,810 5,090 6,290 7,490 8,090 8,290 8,490 9,470 10,460 11,260 12,060

$100,000 - 124,999 2,040 3,830 5,110 6,310 7,510 8,430 9,430 10,430 11,430 12,420 13,520 14,620

$125,000 - 149,999 2,040 3,830 5,110 7,030 9,030 10,430 11,430 12,580 13,880 15,170 16,270 17,370

$150,000 - 174,999 2,360 4,950 7,030 9,030 11,030 12,730 14,030 15,330 16,630 17,920 19,020 20,120

$175,000 - 199,999 2,720 5,310 7,540 9,840 12,140 13,840 15,140 16,440 17,740 19,030 20,130 21,230

$200,000 - 249,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930

$250,000 - 399,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,440 19,730 20,830 21,930

$400,000 - 449,999 2,970 5,860 8,240 10,540 12,840 14,540 15,840 17,140 18,450 19,940 21,240 22,540

$450,000 and over 3,140 6,230 8,810 11,310 13,810 15,710 17,210 18,710 20,210 21,700 23,000 24,300

Head of Household

Higher Paying Job

Annual Taxable

Wage & Salary

Lower Paying Job Annual Taxable Wage & Salary

$0 - 9,999

$10,000 - 19,999

$20,000 - 29,999

$30,000 - 39,999

$40,000 - 49,999

$50,000 - 59,999

$60,000 - 69,999

$70,000 - 79,999

$80,000 - 89,999

$90,000 - 99,999

$100,000 - 109,999

$110,000 - 120,000

$0 - 9,999 $0 $830 $930 $1,020 $1,020 $1,020 $1,480 $1,870 $1,870 $1,930 $2,040 $2,040

$10,000 - 19,999 830 1,920 2,130 2,220 2,220 2,680 3,680 4,070 4,130 4,330 4,440 4,440

$20,000 - 29,999 930 2,130 2,350 2,430 2,900 3,900 4,900 5,340 5,540 5,740 5,850 5,850

$30,000 - 39,999 1,020 2,220 2,430 2,980 3,980 4,980 6,040 6,630 6,830 7,030 7,140 7,140

$40,000 - 59,999 1,020 2,530 3,750 4,830 5,860 7,060 8,260 8,850 9,050 9,250 9,360 9,360

$60,000 - 79,999 1,870 4,070 5,310 6,600 7,800 9,000 10,200 10,780 10,980 11,180 11,580 12,380

$80,000 - 99,999 1,900 4,300 5,710 7,000 8,200 9,400 10,600 11,180 11,670 12,670 13,580 14,380

$100,000 - 124,999 2,040 4,440 5,850 7,140 8,340 9,540 11,360 12,750 13,750 14,750 15,770 16,870

$125,000 - 149,999 2,040 4,440 5,850 7,360 9,360 11,360 13,360 14,750 16,010 17,310 18,520 19,620

$150,000 - 174,999 2,040 5,060 7,280 9,360 11,360 13,480 15,780 17,460 18,760 20,060 21,270 22,370

$175,000 - 199,999 2,720 5,920 8,130 10,480 12,780 15,080 17,380 19,070 20,370 21,670 22,880 23,980

$200,000 - 249,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870

$250,000 - 349,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,770 24,870

$350,000 - 449,999 2,970 6,470 8,990 11,370 13,670 15,970 18,270 19,960 21,260 22,560 23,900 25,200

$450,000 and over 3,140 6,840 9,560 12,140 14,640 17,140 19,640 21,530 23,030 24,530 25,940 27,240

Page 15: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Note: For tax years beginning on or after January 1, 2017, the personal exemption allowance, and additional allowances if you or your spouse are age 65 or older, or if you or your spouse are legally blind, may not be claimed on your Form IL-1040 if your adjusted gross income for the taxable year exceeds $500,000 for returns with a federal filing status of married filing jointly, or $250,000 for all other returns. You may complete a new Form IL-W-4 to update your exemption amounts and increase your Illinois withholding.

How do I figure the correct number of allowances?Complete the worksheet on the back of this page to figure the correct number of allowances you are entitled to claim. Give your completed Form IL-W-4 to your employer. Keep the worksheet for your records.

If you have more than one job or your spouse works, your withholding usually will be more accurate if you claim all of your allowances on the Form IL-W-4 for the highest-paying job and claim zero on all of your other IL-W-4 forms.

How do I avoid underpaying my tax and owing a penalty?You can avoid underpayment by reducing the number of allowances or requesting that your employer withhold an additional amount from your pay. Even if your withholding covers the tax you owe on your wages, if you have non-wage income that is taxable, such as interest on a bank account or dividends on an investment, you may have additional tax liability. If you owe more than $500 tax at the end of the year, you may owe a late-payment penalty or will be required to make estimated tax payments. For additional information on penalties see Publication 103, Uniform Penalties and Interest. Visit our website at tax.illinois.gov to obtain a copy.

Where do I get help?

• Visit our website at tax.illinois.gov • Call our Taxpayer Assistance Division at 1 800 732-8866 or 217 782-3336 • Call our TDD (telecommunications device for the deaf) at 1 800 544-5304 • Write to ILLINOIS DEPARTMENT OF REVENUE PO BOX 19044 SPRINGFIELD IL 62794-9044

Illinois Department of Revenue

Form IL-W-4 Employee’s and other Payee’s Illinois Withholding

Allowance Certificate and Instructions

IL-W-4 (R-12/19)

Note: These instructions are written for employees to address withholding from wages. However, this form can also be completed and submitted to a payor if an agreement was made to voluntarily withhold Illinois Income tax from other (non-wage) Illinois income.

Who must complete Form IL-W-4? If you are an employee, you must complete this form so your employer can withhold the correct amount of Illinois Income Tax from your pay. The amount withheld from your pay depends, in part, on the number of allowances you claim on this form.

Even if you claimed exemption from withholding on your federal Form W-4, U.S. Employee’s Withholding Allowance Certificate, because you do not expect to owe any federal income tax, you may be required to have Illinois Income Tax withheld from your pay (see Publication 130, Who is Required to Withhold Illinois Income Tax). If you are claiming exempt status from Illinois withholding, you must check the exempt status box on Form IL-W-4 and sign and date the certificate. Do not complete Lines 1 through 3.

If you are a resident of Iowa, Kentucky, Michigan, or Wisconsin, or a military spouse, see Form W-5-NR, Employee’s Statement of Nonresidence in Illinois, to determine if you are exempt.

If you do not file a completed Form IL-W-4 with your employer, if you fail to sign the form or to include all necessary information, or if you alter the form, your employer must withhold Illinois Income Tax on the entire amount of your compensation, without allowing any exemptions.

When must I submit this form?You should complete this form and give it to your employer on or before the date you start work. You must submit Form IL-W-4 when Illinois Income Tax is required to be withheld from compensation that you receive as an employee. You may file a new Form IL-W-4 any time your withholding allowances increase. If the number of your claimed allowances decreases, you must file a new Form IL-W-4 within 10 days. However, the death of a spouse or a dependent does not affect your withholding allowances until the next tax year.

When does my Form IL-W-4 take effect?If you do not already have a Form IL-W-4 on file with your employer, this form

will be effective for the first payment of compensation made to you after this form is filed. If you already have a Form IL-W-4 on file with this employer, your employer may allow any change you file on this form to become effective immediately, but is not required by law to change your withholding until the first payment of compensation is made to you after the first day of the next calendar quarter (that is, January 1, April 1, July 1, or October 1) that falls at least 30 days after the date you file the change with your employer.

Example: If you have a baby and file a new Form IL-W-4 with your employer to claim an additional allowance for the baby, your employer may immediately change the withholding for all future payments of compensation. However, if you file the new form on September 1, your employer does not have to change your withholding until the first payment of compensation is made to you after October 1. If you file the new form on September 2, your employer does not have to change your withholding until the first payment of compensation made to you after December 31.

How long is Form IL-W-4 valid?Your Form IL-W-4 remains valid until a new form you have submitted takes effect or until your employer is required by the Department to disregard it. Your employer is required to disregard your Form IL-W-4 if

• you claim total exemption from Illinois Income Tax withholding, but you have not filed a federal Form W-4 claiming total exemption, or

• the Internal Revenue Service (IRS) has instructed your employer to disregard your federal Form W-4.

What is an “exemption”?An “exemption” is a dollar amount on which you do not have to pay Illinois Income Tax that you may claim on your Illinois Income tax return.

What is an “allowance”?The dollar amount that is exempt from Illinois Income Tax is based on the number of allowances you claim on this form. As an employee, you receive one allowance unless you are claimed as a dependent on another person’s tax return (e.g., your parents claim you as a dependent on their tax return). If you are married, you may claim additional allowances for your spouse and any dependents that you are entitled to claim for federal income tax purposes. You also will receive additional allowances if you or your spouse are age 65 or older, or if you or your spouse are legally blind.

Page 16: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Illinois Withholding Allowance Worksheet

Step 1: Figure your basic personal allowances (including allowances for dependents)

Check all that apply:

No one else can claim me as a dependent.

I can claim my spouse as a dependent.

1 Enter the total number of boxes you checked. 1 _______________

2 Enter the number of dependents (other than you or your spouse) you will claim on your tax return. 2 _______________

3 Add Lines 1 and 2. Enter the result. This is the total number of basic personal allowances to which you are

entitled. You are not required to claim these allowances. The number of basic personal allowances that you

choose to claim will determine how much money is withheld from your pay. See Line 4 for more information. 3 _______________

4 Enter the total number of basic personal allowances you choose to claim on this line and Line 1 of

Form IL-W-4 below. This number may not exceed the amount on Line 3 above, however you can claim as

few as zero. Entering lower numbers here will result in more money being withheld(deducted) from your pay. 4 _______________

Step 2: Figure your additional allowances Check all that apply:

I am 65 or older. I am legally blind.

My spouse is 65 or older. My spouse is legally blind.

5 Enter the total number of boxes you checked. 5 _______________

6 Enter any amount that you reported on Line 4 of the Deductions Worksheet

for federal Form W-4 plus any additional Illinois subtractions or deductions. 6 _______________

7 Divide Line 6 by 1,000. Round to the nearest whole number. Enter the result on Line 7. 7 _______________

8 Add Lines 5 and 7. Enter the result. This is the total number of additional allowances to which

you are entitled. You are not required to claim these allowances. The number of additional allowances

that you choose to claim will determine how much money is withheld from your pay. 8 _______________

9 Enter the total number of additional allowances you elect to claim on Line 2 of Form IL-W-4, below. This

number may not exceed the amount on Line 8 above, however you can claim as few as zero. Entering lower

numbers here will result in more money being withheld(deducted) from your pay. 9 _______________

IMPORTANT: If you want to have additional amounts withheld from your pay, you may enter a dollar amount on Line 3 of Form IL-W-4

below. This amount will be deducted from your pay in addition to the amounts that are withheld as a result of the allowances you have

claimed.

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

General InformationUse this worksheet as a guide to figure your total withholding allowances you may enter on your Form IL-W-4.

Complete Step 1.

Complete Step 2 if

• you (or your spouse) are age 65 or older or legally blind, or

• you wrote an amount on Line 4 of the Deductions Worksheet for federal Form W-4.

Illinois Department of Revenue

IL-W-4 Employee’s Illinois Withholding Allowance Certificate

____ ____ ____ - ____ ____ - ____ ____ ____ ____Social Security number

________________________________________________________________________Name

________________________________________________________________________Street address

________________________________________________________________________City State ZIP

Check the box if you are exempt from federal and Illinois Income Tax withholding and sign and date the certificate.

IL-W-4 (R-12/19)

If you have more than one job or your spouse works, your withholding usually will be more accurate if you claim all of your allowances on the Form IL-W-4 for the highest-paying job and claim zero on all of your other IL-W-4 forms.

You may reduce the number of allowances or request that your employer withhold an additional amount from your pay, which may help avoid having too little tax withheld.

Employer: Keep this certificate with your records. If you have referred the employee’s federal certificate to the IRS and the IRS has notified you to disregard it, you may also be required to disregard this certificate. Even if you are not required to refer the employee’s federal certificate to the IRS, you still may be required to refer this certificate to the Illinois Department of Revenue for inspection. See Illinois Income Tax Regulations 86 Ill. Adm. Code 100.7110.

1 Enter the total number of basic allowances that you

are claiming (Step 1, Line 4, of the worksheet). 1 ____________

2 Enter the total number of additional allowances that

you are claiming (Step 2, Line 9, of the worksheet). 2 ____________

3 Enter the additional amount you want withheld

(deducted) from each pay. 3 ____________

I certify that I am entitled to the number of withholding allowances claimed on

this certificate.

______________________________________________________________________Your signature Date

This form is authorized under the Illinois Income Tax Act. Disclosure of this information is required. Failure to provide information may result in this form not being processed and may result in a penalty.

Printed by the authorityof the State of Illinois - web only, 1 copy

Page 17: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � �! � � � � � " � � � � � # � " � � � � � � $ � � � ! � � � � � � � � � � � � � � � � � � � � � $ � � � # � " � � � � � $ � � � � � � � "! � � � � � � � � " � � %! � � � � � � � � � � � � � � � � � " � � � � � � � � $ � � � % � & � � � � � � � " � � � � � � � � � $ � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � " � ' � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � % � � � � � � � � ( � � � � % � $ � � � � � � � � $ � $ � � ( � � � � % � � � � � � �( � � � � � � � � � � � � % ) $ $ � � � � � � � � * � � � � � � � % � � � � $ � � * � � � � � � � � � � � � � � $ � * � � � � � � � ' + � � � � � � � $ � � � � � � � � � � � � & � $ � � � � � � � �� � � � � � � � � � � � � � � � & � � � � � � � � � � " � � � � � � � � � � � � ', � � � $ � � � � " � � � � � � � � � � � � � � � � � � � � � � � � � $ � � % � � � � � � � � � - � � � � � � $ � � � � $ � � � � $ � � � � � � � � � � � � � & � � � � � " � � � � � � � � � $ �� � � � � � � � � � � � � � � � � � � ' � � � � � � � � � � $ � " � � � � � � � � � � � � " � � � � � � � � � � � � " � � � � � � " � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� " � � � � " � � � % � " � � � � � � � � � � � � � � � � " � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � $ � � � � � � � � '. / 0 1 2 0 3 4 5 6 / 0 7 0 1 2 0 6 1 8 1 7 0 9 4 8 5 9 4 8 0 1 3 : ; < = > ? > = @ 1 / . 8 4 ? > = 0 8 A 4 @ @ 2 0 1 < = 2 @ B 5 > 7 C > 7 :4 7 : 0 8 8 0 D @ > 8 0 = 6 1 6 0 8 C 4 8 E 7 4 A 4 @ 8 F 4 5 0 G 0 8 ? > 3 0 2 . 8 4 H 8 1 5 4 9 9 > 3 0; < = > ? > = @ 1 / . 8 4 ? > = 0 8 ; < 9 4 8 5 1 7 > 4 < I� ' ( � " � J � ' K � � � � � L � � � M � " � � �N ' O � � � � � � � � L L P ! ! P + + + + J � ' � � � � � ( � " � � � � � $ � � � � � � � � $ � � � J

Q ' * � � � � � � � � � � � � � � � � � R � � � � � � � � � � � � � � � � � � � � � " � � SM � " � � M � � � � � � � � � � � �

T ' � � � � � � � � � � �� , � � � � � � � � � � � � � � � � � � � � � � � $ � � � � � � � � � � U ' L � � � � � � � � � �� , � � � � � � � � � � � � � � � � � � � � � � & � � � � $ � � � � � P � � � $ � � $ V W ' � � � � � � � � � � � � � � � � " � � � � � � � � � % � � � � � $ � � � � % � � � � � � � $ � � � � $ $ � � � � � � � � � � � $ � � � $ � � � � " � � � � � � � � � � � � � � � � $ � " � � � � J

� � � � � � � � � $ � � J

� ' * � � � � � � � � � � � � � � � � � � J � � � � � � � $ � � $ V � � � � � � � � � � $ � � � � � � � � � � � T � � � � � � � � � � � � � � � � " � � � � � � � � � � � $ � � � � � � � � � % � � � � � � " � � � � " � � � $ � � � � $ � � � � � � " � � � � � � � � � � � �� � - � � � " � � � � � � � � � � � � � � � � � � � � & % � � � & � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� U � � � � � � � � � � � � � � � � � � � � � � � � � � $ � � � � � " � � � � � � � � � " � � � � � � � � � � � $ � � � � � � � � � � W � � � � � � � � � � � � � � � � � � � � � � � � � � � � � $ � � � �� � � � � � � % � � � � � � � � � � � � � � � � � �

Page 18: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � �! � � � � � " � � � � � # � " � � � � � � $ � � � ! � � � � � � � � � � � � � � � � � � � � � $ � � � # � " � � � � � $ � � � � � � � "� ' * � � � � � � � � � � � � � � � � � R � � � � � � � � � X � � � � � $ � � � � P � � � � � � � � � � � � � - � � � � � � � $ � � � � � � � � & � � � � � � � � $ � $ � � � V � � � � � � � " � �� � � " � � " � � � " � � � � � � � � � � � � � � & JY Z [ \ ] ^ _ ` a b ` c d ` e Y a Z b c b c f� � ' � � � � � � � � � � � � � � � � � � � � & � � � � � � � � " � $ � � � � � � � � � � � � $ � � � � � � V � % & � � � � � � � � " � � � � � � � � � � � � � � � � � � � � � " " � � � � � $ � �� � � � � � � � � � � � � � � � � � � " � � $ � � � � � � � � � � � � � � � � � � � � � � � � � � � � # � " � � � � � $ � � � � � � � " '( � � � � � � $ � � � � + � � ( �� � ' * � � � � � � � � � � � � � � � � � � � � � � " � � � � � � � � � � � � � � � � $ � � � � � � � � � � � � � � � � � g � � � � � � � � � � $ � � � � � � � � � � & � � " � � � " � � � � � � '+ � � ( �� N ' * � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � # � " � � � � � $ � � � � � � � " & � � � $ � � � � � � � P � � � � � $ � � � � $ � � � � $ � � � � � � � � � �� � $ � " � � � � � � � � � � � � � � � � � � � � " � � � � '( �+ � �� � ' * � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � # � " � � � � � $ � � � � � � � " & � � � $ � " � � � � � � h " � � � � " � � � h � � � � � i � � � $ � � � � � � � "� � � Q % g ' � ' ! � � � � � " � � � � � j � � � $ � � � � � & � � � � � � � - � � � � � � � � " � � � � � � � � � $ $ � " � � � � � � '+ � � ( �� T ' * � � � � � � � � � � � � � � � � � � � � � � $ � � � � % $ � " � � � � � � � � � � � � � � � � , � � � � � � � � � " � � � � � � � � � � � " � � � � � � � � � � $ � � � � � � � � �� � � � � � L � � $ � � � � � � � � � $ � � � � � � " � � � " � � � & � � � � � " � � � � � � � # � " � � � � � $ � � � � � � � " � � � $ � '( �+ � �� � � � � � � $ � � � � � � � � � � � � � � � � � " � � � � � � � � � � � � � $ $ � � � � � � � � � � � � � � � � " � V � � & � � � � ' � � � � � � � � $ � � � � � � � � � � � � � � � � � � � � � � �� � " � � � � � � � � � � � � � � � � $ � � � � $ � " " � � $ � � � � � V � � � � � � � � � � � � � $ � � $ � � � $ � � � � " � � � " � � � � � � � � � � � P � � � $ � � � � � � � � $ � � � � �� � � � � & � � � $ � � � � � � � � $ � " � � � � � � � � � � � V � � � � � � � " � � '� � � � � � � � � � � � � � � � $ � � � � � � � � � � � � � � � � � � " � � � � � � " � " � � k � � � � � � l � � � � " � � � � � � � � � � � � � � � � � � � � � � � � � � " � � � $ � � � � � � � $ � � � � � � � � � � � # � " � � � � � $ � � � � � � � " '� � � � � � � � � � � � � � " � � ! � � �

( � L h � ) M � ( ! � i � ! g � � � � ) i � ! h � � � h M h � � h ! * ) � g � * ) L h � � O + * # h ! h � � � * L h ( * ) M # g L � ( � h � i � � h � �! � i � � � ) ( ) M � h # � O � � � * � * � ) ( � h � i � � h � � # ) g � ! O h � ) ( � � ! h � h ! � � � ) * h ( * � � � , ) � m h � � � ( ! ( ) *� h � ) L L h ( ! � * � ) ( � * ) g � h * # � * � ( ! � i � ! g � � ' � g � * ) L h � � L � m h * # h � ( ! � i � ! g � � � � ) i � ! h � � � � h � h � * � ) ( � ( !� # ) g � ! � # h � m � � � � h M h � h ( � h � P � h � ) L L h ( ! � * � ) ( � � � � ) � * ) g � � ( K � ( � ( ! � i � ! g � � ' ! � � �� � � � � � � � � � � � � � � % K � � � � � � � � � � � � � � � � � � � � �� � � � � � ( � " � � � � � � � % K � � � � � � � � � � � � � � � � � � � � �

; < = > ? > = @ 1 / . 8 4 ? > = 0 8 ; < 9 4 8 5 1 7 > 4 < I n 3 4 < 7 > < @ 0 = o

Page 19: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � � � � � � � � � � � � � � � � � ! � " � � � � � ! ! � � � # � $ " � � � � � � � � � ! � � � � ! � � � # � % $ � � � � � � % � � � � � � � � � � � � � � � � � � � � � � � � � � ! � " � � � � �

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•

R H O N E X Y B K L > E E G I \ D B G I O I ? K = = I K J H G K L B ? K L I @ ? A B C B A D > E F G H C B A I G F > X O I ? K F H E B R B I = ] @ ^ _ ` ` a b b c b d T K L I V > B C I G F G H S G > OF G H C B A I G < S G I I O I ? K ] @ ^ _ ` ` a b b e b @ U F < f g Y > B C I G d T > ? A K L I @ U F < f g @ ? A B C B A D > E F G H C B A I G h ? G H E E O I ? K i H G O] @ ^ _ ` ` a b b e j d k •

? H K A B = R G B O B ? > K I B ? K L I N G H C B = B H ? H J = I G C B R I = W > = I A H ? K L I S G H D ? A = H J = I l T G > R I T R H E H G T ? > K B H ? > E H G B S B ? H G A B = > W B E B K X k •

R H O N E X Y B K L F I G = H ? > E < = = B = K > ? K ] F < d T f I G K B J B I A m D G = B ? S < = = B = K > ? K ] f m < d T n I S B = K I G I A m D G = I ] n m d T > ? A o H G ^ B R I ? = I AF G > R K B R > E m D G = I ] ^ F m d G I \ D B G I O I ? K = > = = I K J H G K L B ? ` p @ E E Z < A O Z f H A I e ` e Z q r T > ? A o H G K L I s s @ E E Z < A O Z f H A I j p c k •

R H O N E X Y B K L P Q F t = h E I R K G H ? B R u B = B K u I G B J B R > K B H ? > ? A g B O I v I I N B ? S Q X = K I O ] h u u d > = O > ? A > K I A W X K L I Q U < n g < R Kp s a r e ` p T Q I R K B H ? c Z c ] J d w ] S d k •

W I > R R D G > K I T R H O N E I K I > ? A K G D K L J D E B ? R H O N E I K B H ? H J K L I P x U h Q h n u @ f h Q g @ U h Q P h h g ] @ ^ _ ` ` a b b c q d T > ? A W X= B S ? B ? S K L I @ ^ _ ` ` a b b c q T @ > S G I I K H W I J D E E X E B > W E I J H G K L I B ? J H G O > K B H ? K L I J H G O R H ? K > B ? = ] < ? X = D W O B = = B H ? H J J > E = I H GJ G > D A D E I ? K W B E E B ? S T H G > ? X R H ? R I > E O I ? K H J B ? J H G O > K B H ? G I E I C > ? K K H N > X O I ? K H J K L I = I W B E E = O > X W I N G H = I R D K I A D ? A I G> N N E B R > W E I i I A I G > E > ? A Q K > K I E > Y = d k •

O > B ? K > B ? > R H N X H J K L I R H O N E I K I A P x U h Q h n u @ f h Q g @ U h Q P h h g ] @ ^ _ ` ` a b b c q d > ? A > ? X H K L I G G I R H G A = G I E > K I A K HK L I W B E E B ? S = I G C B R I = N > B A W X K L I M B C B = B H ? H J n I L > W B E B K > K B H ? Q I G C B R I = ] g L I = I G I R H G A = O D = K W I O > B ? K > B ? I A J H G > K E I > = KK L G I I ] j d X I > G = J G H O K L I A > K I K L I = I G C B R I Y > = W B E E I A Z d k •

? H K B J X @ M P Q a M n Q B J K L I G I B = > ? H C I G N > X O I ? K J H G > ? X = I G C B R I N G H C B A I A > ? A G I K D G ? > ? X H C I G N > X O I ? K K H K L I Q K > K I H J@ E E B ? H B = Z@ > S G I I K L > K = L H D E A K L I B ? J H G O > K B H ? N G H C B A I A W I B ? R H O N E I K I T B ? > R R D G > K I T H G J > E = B J B I A T B K O > X W I R > D = I J H G O X K I G O B ? > K B H ? > => ? @ M P Q a M n Q F G H C B A I G D ? A I G K L I P H O I Q I G C B R I = F G H S G > O Z4 y z { | y } ~ � { � { � z � � � { - � � � � � � � � � / � y � � � { �< E E J B I E A = > G I G I \ D B G I A > ? A } � � � z { | y } ~ � { � { Z F E I > = I N G B ? K R E I > G E X K H > C H B A A I E > X = ZF E I > = I = I E I R K = I G C B R I K X N I N G H C B A I A [ ] = I E I R K > E E K L > K > N N E X d] F < d ] f m < d ] n m d ] ^ F m dF I G = H ? > E < = = B = K > ? K f I G K B J B I A m D G = B ? S < = = B = K > ? K n I S B = K I G I A m D G = I ^ B R I ? = I A F G > R K B R > E m D G = Ii D E E F G B ? K I A m > O I [� � � � � � � � � � � � � Q Q m [ M x � [@ ? A B C B A D > E F G H C B A I G Q B S ? > K D G I [P Q F f D = K H O I G i D E E m > O I [ 4 y z { | y } ~ � { � { � z � � � { & * / : � { � � ' � � � | {< E E J B I E A = > G I G I \ D B G I A > ? A } � � � z { | y } ~ � { � { Z F E I > = I N G B ? K R E I > G E X K H > C H B A A I E > X = ZP Q F f D = K H O I G M B = K G B R K m D O W I G [ P Q F f D = K H O I G f > = I m D O W I G [P Q F x J J B R I ^ H R > K B H ? m > O I [P Q F Q K > J J F G B ? K I A m > O I [P Q F Q K > J J � H W g B K E I [P Q F Q K > J J Q B S ? > K D G I [ M > K I [

M > K I [

Page 20: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 21: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � � � � � � ! � " � � � " � � � � � � � " � � � # � � � � � � � � � � � � � � " � # $ � � � � � � # � � � � � � � � � � � � � � � � � � � � � % � � � � � � � � � � �

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•

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•

F 2 / G ' 5 6 / - 8 ) 6 ? ) ? ' ( ) B - : : ' 7 : > < ) 2 ; ; + ' , ) 8 - = 6 ? ) . 5 / 6 ' ( ) + 8 ' ) / 7 ' 6 ? 2 , ) 2 8 ) C 5 2 6 ) = 2 . - : - 6 - ) / @I Y 2 ( ; : ) / - 7 . : 5 8 ) \ 9 7 8 - , - 8 5 2 : 0 + ' , - 8 ) + 5 / - 7 1 2 : 2 5 7 8 + > = 2 . - : - 6 > - = 6 ? ) A 5 / 6 ' ( ) + 8 ' ) / 7 ' 6 ? 2 , ) 2B 2 / ? ) + 2 7 8 8 + > ) + H < 2 7 G - 7 1 2 7 8 1 + ' . ) + > / ? ' ; ; - 7 1 @ •

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` N _ a b c F a N * N _ 9 _ b 9 M 9 b c N ] 0 O ^ M 9 b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

Page 22: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � � � � � � � � � � � � � � ! � " � � � " � � � � � � � " � � � # � � � � � � � � � � � � � � " � # $ � � � � � � # � � � � � � � � � � � � � � � � � � � � � % � � � � � � � � � � � �

9 6 - / 2 1 2 - 7 / 6 2 8 ( - 7 - / 6 + 2 6 - , ) + 5 : ) / = ' + : ) 1 2 : : > + ) / ; ' 7 / - < : ) + ) : 2 6 - , ) / 6 ' / ) + , ) 2 / 6 ? ) 9 7 8 - , - 8 5 2 : 0 + ' , - 8 ) + = ' + & * 0. 5 / 6 ' ( ) + / @ F ? - / - 7 . : 5 8 ) / 2 / ; ' 5 / ) B ' + G - 7 1 = ' + ? - / J ? ) + 8 - / 2 < : ) 8 / ; ' 5 / ) Z . ? - : 8 + ) 7 5 7 8 ) + 6 ? ) 2 1 ) ' = d U B ' + G - 7 1 = ' + 6 ? ) - +8 - / 2 < : ) 8 ; 2 + ) 7 6 Z ' + 2 ; 2 + ) 7 6 H / 6 ) ; R ; 2 + ) 7 6 H ' + = ' / 6 ) + ; 2 + ) 7 6 B ' + G - 7 1 2 / 2 7 9 7 8 - , - 8 5 2 : 0 + ' , - 8 ) + = ' + ? - / J ? ) + 8 - / 2 < : ) 8 . ? - : 85 7 8 ) + 6 ? ) 2 1 ) ' = d U @ 9 7 8 - , - 8 5 2 : 0 + ' , - 8 ) + / 2 7 8 . 5 / 6 ' ( ) + / . 2 7 + ) C 5 ) / 6 . : 2 + - = - . 2 6 - ' 7 2 6 2 7 > 6 - ( ) 6 ? ) + ) ( 2 > < ) 2 C 5 ) / 6 - ' 7' + . ' 7 . ) + 7 2 < ' 5 6 6 ? - / - / / 5 ) @9 7 8 - , - 8 5 2 : 0 + ' , - 8 ) + / . 2 7 7 ' 6 . ? 2 + 1 ) & * 0 = ' + 6 ? ) / 2 ( ) ? ' 5 + / B ' + G ) 8 B ? ) 7 B ' + G - 7 1 2 7 ' 6 ? ) + e ' < @ F ? - / - 7 . : 5 8 ) / B ' + G - 7 1= ' + ' 6 ? ) + & * 0 . 5 / 6 ' ( ) + / ' + 2 / 2 . ? - : 8 . 2 + ) ; + ' , - 8 ) + ; 2 - 8 6 ? + ' 5 1 ? 6 ? ) b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`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d R U S S R U S f R g U g g B ? ) 7 ) , ) + - 7 = ' + ( 2 6 - ' 7. ' 7 . ) + 7 - 7 1 . ? ) . G / ( - 1 ? 6 < ) 7 ) ) 8 ) 8 @ F ? - / / > / 6 ) ( . 2 7 , ) + - = > 6 ? 2 6 < - : : - 7 1 - 7 = ' + ( 2 6 - ' 7 B 2 / + ) . ) - , ) 8 2 7 8 ; + ' . ) / / ) 8 = ' +; 2 > ( ) 7 6 H - 7 . : 5 8 - 7 1 6 ? ) ) Y ; ) . 6 ) 8 2 + + - , 2 : 8 2 6 ) ' = 6 ? ) . ? ) . G / @ 0 ? ' 7 ) . 2 : : / 6 ' 6 ? ) : ' . 2 : ' = = - . ) / 8 5 + - 7 1 ; 2 > ( ) 7 6 . > . : ) / . 2 7; ' 6 ) 7 6 - 2 : : > 8 ) : 2 > ; 2 > ( ) 7 6 / 6 ' 9 7 8 - , - 8 5 2 : 0 + ' , - 8 ) + / < ) . 2 5 / ) ' = 6 ? ) , ' : 5 ( ) ' = 8 2 6 2 ) 7 6 + > + ) C 5 - + ) 8 ' = 6 ? ) = - ) : 8 / 6 2 = = @0 ) + / ' 7 2 : N / / - / 6 2 7 6 / 2 + ) . ' , ) + ) 8 = ' + . ' : : ) . 6 - , ) < 2 + 1 2 - 7 - 7 1 ; 5 + ; ' / ) / < > 6 ? ) * ) + , - . ) I ( ; : ' > ) ) 9 7 6 ) + 7 2 6 - ' 7 2 : c 7 - ' 73 * I 9 c 4 & ) 2 : 6 ? A 2 + ) 9 : : - 7 ' - / J 9 7 8 - 2 7 2 3 2 / ( 2 7 8 2 6 ) 8 < > 6 ? ) * I 9 c A ' : : ) . 6 - , ) K 2 + 1 2 - 7 - 7 1 N 1 + ) ) ( ) 7 6 B - 6 ? 6 ? ) * 6 2 6 ) ' =9 : : - 7 ' - / 4 @ I 2 . ? ; 2 > ; ) + - ' 8 H 2 8 ) 8 5 . 6 - ' 7 B - : : < ) 6 2 G ) 7 = + ' ( 2 7 0 N L / B 2 1 ) / 6 ' . ' , ) + ' 7 ) ' = 6 ? ) = ' : : ' B - 7 1 \ 3 d 4 ( ) ( < ) + / ? - ;. ' / 6 / 6 ' e ' - 7 * I 9 c H ' + 3 h 4 2 i = 2 - + / ? 2 + ) 8 ) 8 5 . 6 - ' 7 i - = 2 0 N 8 ' ) / 7 ' 6 e ' - 7 * I 9 c @ F ? ) + 2 6 ) / = ' + ( ) ( < ) + / ? - ; H = 2 - + / ? 2 + ) 2 7 8( 2 Y - ( 5 ( ( ' 7 6 ? : > 8 5 ) / 2 + ) ; ' / 6 ) 8 ' 7 6 ? ) O ) ? 2 < - : - 6 2 6 - ' 7 * ) + , - . ) / 0 + ' , - 8 ) + 9 7 = ' + ( 2 6 - ' 7 / ) . 6 - ' 7 i = ' + 0 + ' , - 8 ) + / i ; 2 1 ) 2 6B B B @ 8 ? / @ / 6 2 6 ) @ - : @ 5 / @ 9 = > ' 5 ? 2 , ) 2 C 5 ) / 6 - ' 7 2 < ' 5 6 5 7 - ' 7 ( ) ( < ) + / ? - ; 8 5 ) / ; : ) 2 / ) . ' 7 6 2 . 6 * I 9 c 2 6 d R U T T R P g g R Q g f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� � � �� � � �

Page 23: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � ! � � " � � � � # � � � ! � � � " � $ %

� & ' ( ( � ) ) * ) + � � , - � . * / 0 � � � � � � � � � � � � � 1 � 2 � � � � � � � � � � 1 � 3 2 � � � � � � 3 � � � � � � � � � � � � � � � � � � � , � 4 � � � � � � � � . � � )

5 � � � � � � � 6 � � � � � � � � 7 � 1 � � � � 1 0 � � � � � � � � 1 � � � � � � 7 � 2 4 8 � 3 � � �� � � � � � � � � � � � � � � 1 � � 9 � � � � � � � � � � � � 1 � � � � � � � � 3 � � � � : � � 3 ) , . - ; 8 � � � 9 9 � � � � � � 1 3 � � � � < � 9 � � � � � � � 7 � 1 � � � � 1 � � � � � 2 1 � � � � 1 4 � � � 1 8 � � � � � � � 3 + � 7 � 2 4 8 / ; � 7 � 2 4 8 9 � � � � � � � 1 � 3 � � � 7 � 1 � � � � 1 � 1 0 � � � � � � � � � � � � � 1 � 1 � � � � � � � 9 � � � � � � � � � ; 2 � � � 1 � � � 1 � � � � � � � 1 � � � < � � � � � � � � 1 � � � � � � 9 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � + � � � � � � � / 7 � 1 � � � � 1 0 � � � � � � � � � 9 � � � � � � = � � � 1 � � � � � � � � � 1 � � 7 � 2 4 8 ; � � � 9 � � � � � � � � � � � � 1 � � � 1 � � � � � � � 1 � � � � �� 7 � 2 4 8 3 � � � ; � � 1 � � � � � � � � � � � � � � � � � � � � � 9 � � � � � � � � � � � � � � � 3 � � � � � � � � � � � � � � � 1 � � � 1 � � � � � � � 1 � ; 8 � �� 1 � � � 1 � � � � � � � 1 � � 3 � � � � � � � 0 � � � � � � � � � � � � � 1 � 2 � � � � � � � � � � � � � � � � � � � 1 � � 1 � � � � � � � � � 8 � 1 � � � � � � � � � � � � � � � � � � 7 � 2 4 8 � � � � 1 � 6 � � � � � � � 3 � � � ; 8 � � � � � � � � � � � � � � � � 7 � 2 4 8 � � � � 1 � 6 � � � � � � 8 � � � 14 � 1 � � � � � � � � � � � 1 � � � � � � > ? ? 9 9 9 ; � � � � � � ; � � � ? � � ? � � � � � � ? � � � � � � � ? � 6 @ 8 � � @ 4 � 1 � � � � ; � 1 �A B C D E F G F H I F B J G F H D C K E F B I F E E J E L M0 � 6 � 6 2 � N N � � � � � � � � � � � � 1 � � � O � � � � � � � 1 � O N � � � � � � 1 9 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1 P � � � � 3 � � � � � � N � � � � � � � � � � � � 1 � � � O � P � O N � � � � � � � � � � � � � � 1 � � � � � 7 � 1 � � � � 2 � � � � �� � � � � Q � 10 � 6 � 6 2 � N � � � � � � � 1 � � � � � � � � 9 � � � � � � � � � � � � � � � � � � � � � � � � � � N � � � � � � � � � � � � � � � � � � � � � � � � � � � + � � � � � � � /+ � � � � � � � � � � � � 1 � � � O 0 � � � � 2 � � � 3 O / � � � � � � 1 � � � � � � � � 9 � � � � � � � � � � � � � N � � � 9 � � � R � � � S � � � N � 1 ? � � � � 9 � � � � � T ? 2 � � � 0 � � � ;0 � 6 � 6 2 � N � � � � � � � 1 � 9 � � � � � � � � � � � � � � � � � � � � � � � 1 � � 1 � � � � � � � � � � � � � � � � � � � � 1 P � � � � 3 � � � � � � � � � � � � � � � � �� � � 0 � � � � 2 � � � 3 ; 8 � � � � � � 1 � � � � � � � � � � � � � � � � � � 0 � � � � 2 � � � 3 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1 � � � � � � � � � 7 � 1 � � � � 2 � � � � � � � � � � � � � � 1 � ; U 1 � � � � � � � � � � � � S � 3 N � � � � � � � 1 � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � ; 8 � � 0 � � � � 2 � � � 3 9 � � � � � � � � � � � � � � 3 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � � � � � � 2 1 � � � � 1 4 � � � 1 8 � � � � � � � 3 + � 7 � 2 4 8 / � � � � 1 � � � � � � � � 3 � � � ; 8 � � 0 � � � � 2 � � � 3 9 � � �� � � � � � � � � � � � � 1 � V � � � � � � � � � � 1 � � 7 � 2 4 8 � � � � 1 � � N � � � � � � � � � � � 1 � � N � � 1 � � � � � � � � � � � � N � � < � � � � � � � � � � � �� � � � 1 � V � � � � � � � � � � � � 1 � � � � � 1 � � � � � � � � � � � � � � � � � � � ; 8 � � 0 � � � � 2 � � � 3 9 � � � � � � � � � � � � � � � � � � � 3 � � � W � � � � � � � �� � � � 1 � � 1 � � � � � � � � � 8 � 1 � � � � � � � � � � � � � � � � � � 7 � 2 4 8 � � � � 1 � 6 � � � � � � � 3 � � � ;5 X 0 8 � 6 � 6 P X � 6 N � � � � � � � 1 � � � � � � � � � � � 9 � � � � � � � � � � � >. ; 8 � � � � � � 1 � � � � � N � � � � � � � � � � � � N � � � � � 3 9 � � � � � � � � � � � 1 � � � � � � � � � � � � � � � 3 � � � � � � � � � � � � �� � 3 � � � � � � � � � � � � � � � � � 1 � � � < ? � � � � � � � 9 � � � � � � � � � � � � � � � � 1 � � � � � � � 0 � � � � 2 � � � 3 N � � � � � � 7 � 1 � � � � 2 � � � � � � 0 � � � � 2 � � � 3 N � � � � � � � � � � N � � � � � � � � 3 � � � � � � � 1 � � � � � � � � � � � � � � 3 Y , 1 � 3 � � � � � � � � � � � � � � � � � 1 � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3 N � 1 � � � � 1 � � � � 2 1 � � � � � � � � � � � � � 1 � �2 � � N � � � � � � � � � � � � � � � � � 3 9 � � � � � � � � � P � 1 � � � � � 9 � � � � � � � � � ;) ; 8 � � � � � � 1 � � � � � N � � � � � � � � � � � � N � � � � � 3 9 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1 � 1 � � � � � � � 1� � � � � � � � 9 � � � � � � � � � ;Y ; 8 � � � � � � 1 � � � � � � � � � � 3 9 � � � 8 � � � � T � � � � � � 4 � � � � � � � � � 2 � � � � . Z * ' N � � � � � � � � � � � � � � � � 2 � � � � . Z [ Y N � � �2 � � � � � 9 � � � � � � � � � � � � � 2 � � � � . Z Z , N � 1 � � � � � � � � � � � � � � � � � 1 � � � � � 1 � 9 � � � � � � � � � � � 1 � � � � � � � � � � � � � � � � 1 � � � W N � � � N � � � � N � � � � � � � � � � � 1 � � � � � � � 3 ;' ; 8 � � � � � � 1 � � � � � N � � � � � � � � � � � � N � � � � � 3 9 � � � P � 1 � � � � � 1 � 1 � � � � � � � 1 � 8 � � � � \ � \ � � � � � � � � � �� � � � � � 3 2 � � N � 1 � � � 9 � � � � � � � � � � � � � � � � P � 1 � � � � 1 � � � � � � � 9 � 1 � � � � � � � � ;- ; 8 � � � � � � 1 � � � � � � � � � � � 0 � � � � 2 � � � 3 � � 7 � 1 � � � � 2 � � � � � � � � � � 1 � � � � � Q 0 � � � � 2 � � � 3 9 � � � � � � �� � 3 � � � � � � � � � � 1 � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � N � � � � � � � � 1 � � � � � � � � � � � � � � � � 3 2 � � N � � � � � � . Z , ) + � / + ) [ / � 1 + � / + Y ) / ;* ; � � 3 � � � � � � � � � � � � 1 � � 1 � � � � 2 � � � � � � � � � � � � � � � � � � � � 3 � � � � � � � � ; 2 3 � � 3 � � � � � � � � � 1 � 3 � � �� � � � 1 � � � � � � � � � � � � � � � � � � � � 9 � � � � 1 � � � 1 1 � 1 � � � � 1 � � � � � � � � � � 1 � V � � � � � ;[ ; 8 � � � � � � 1 � � � � � � � � � � � 3 � � � � � � � � � � � � � � � N � � � � � � 3 N � 1 � � � � � � � � � � � � � � � � � � � � � � � 3 � � � � � � � � � � 1� � � � � � � � � � � 3 � � � � 1 � � � 3 ; P � � � � � � � N � � � � � � � 1 � � � � � � � � � � � 9 N � � � � W � � � � � � � � � � � � � � N � 1 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ; 2 3 � � � � � � � � 1 � � � � � � � � � � � � � � � � � 3 � � � � � � � � � � � � � � � � � � �� � � � � � 3 � � � � � � � � � 1 � 1 � � � � � � � � � � � P � 1 � � � � 1 � � � � � � � 9 ;( ; 8 � � � � � � 1 � � � � � � � � � � � � � � � � � 1 � � � � 3 � � � � � � 3 1 � � � � � � � � � � � � � 1 � W � � � � � � � � � � � � � � 1 � 1 � �� 1 � � � 1 � � � � 1 � 2 � � � � � T N T � N � 1 T � � � � � � � � � � � � � 2 � 1 4 � 1 � ; 8 � � � � � � 1 � � � � � � � � � � � � � 1 � � � 1 � � � �� � � � � � W + * / 3 � � � � � 1 � � � � � � � � � � � � � = � � � 1 � 3 � � � � � � � � � � P � 1 � � � � 1 � � � � � � � 9 N 9 � � � � � � � � � � � � N � 1 � � � � � � � � � � � � � � � 1 � � � 1 � � � 1 9 � � � � = � � � � 1 � 3 � � � � � � 7 � 1 � � � � 2 � � � � � N � � �0 � � � � 2 � � � 3 � � � � � 1 � � � � � ; � � � � � � � � � � � 1 � � � � 2 � � � � � � � 0 � � � � 2 � � � 3 � � 1 � � � � � � � � � � 1 N � � �� � � � 1 � � � � � � � � � � � � � � � � � � � � � 1 � � � � � � � � � 1 � � � � � � � � � � � 1 � 1 � � � 3 � � 1 � � � � � � � � � � � � � � � 1 N� � � � � � � � � � � � � � � � � � 1 � W � � 1 � � 3 � 1 � � � � = � � � 1 � � � � 1 ; ] ^ _ ` a b ` c d e _ ` ` d f a g h i d j

] k l b ` a m c n n o d i h n p h q d j

Page 24: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � ! � � " � � � � # � � � ! � � � " � $ %� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � ) � � )� & ' ( ( � ) ) * ) + � � , - � . * / 0 � � � � � � � � � � � � � 1 � 2 � � � � � � � � � � 1 � 3 2 � � � � � � 3 � � � � � � � � � � � � � � � � � � � , � 4 � � � �

Z ; � � � � � � � � � � � � � � N � � � � � � � 1 � � � � � � � � � � 3 9 � � � � � � P � 1 � � � � � � � � � � � � = � � � � � 9 � � � � � 1 � � � � �1 � � � � � � � � � 1 � � ' ) 4 P � � � � ' - - N � � � � � � R ;. , ; 8 � � � � � � 1 � � � � � � W � � � � � � � � � � � � � � � � � � � � � � � � � � � � = � � � 1 � 3 � � 1 � � � � 2 � � � � � � � � � � � � � � � 3� � � � � � � < � � � � � � � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � ;. . ; 8 � � � � � � 1 � � � � � � � � � � � 3 � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � � 1 � � � 0 � � � � 2 � � � 3 � � � 3 � � � � � 3 � � � 9 � � � � � � 3 � � � � � � � � � � � � � � 1 � V � � � � � � � � � � � � � � � � 1 � � � � 2 � � � � � � 1 � � � 0 � � � � 2 � � � 3 ; 8 � � � � � � 1 � � � � � � � � � � � � � � � � � � � � � � 3 � � � � 3 � � � � � � � � 7 � 1 � � � � 2 � � � � � � 1 � � � 0 � � � � 2 � � � 3 � � � 3� � � � � 3 � � � � � 9 � � � � � � � � � � � 1 � � � � � � � � 9 � � ; � � � � � � 7 � 1 � � � � 2 � � � � � � 1 � � � 0 � � � � 2 � � � 3 � � � � � � � � � � 3 � � � � � 3 � � � � 3 � � � � � N � � 1 � � � � � � � � � � � � � � � � � � � � � � 3 � = � � � � 1 � � � � � � � 3 � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � � 1 � � � 0 � � � � 2 � � � 3 ;. ) ; 8 � � � � � � � � � � � � � � � � � � � � � � � � � � � � 9 � � � � � � � � � � � � � � � � � � � � 1 � � 3 � � � � � � � � 9 � � � � � � � � � � 1 � � � � 1 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Y , - � & 4 � - ? . ) ' ; ) - ;. Y ; 8 � � � � � � 1 � � � � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � � � � � U ; � ; � � � � � � � � � � � � � � � � � 1 � � � � � � � � � � + � � � � � � � � � � � � 1 � � � O � � � O / � � = � � � N � � � � � � � � � � � � � 1 � � � � � � � � � � � � � � � � � � 1 � � � 9 � � �' ) 4 P � ' - - ; . , - � � � � � � � + � / ; 8 � � � � � � 1 � � � � � � � � � � � � N 9 � � � � Y - 1 � 3 � � � � � � � 1 � � � � � � � � � � � � � � � � � � � � � 1 � � � � � � � � � � � � � � � � � � 1 � � � 9 � � � ' ) 4 P � ' - - ; . , - � � � � � � � + � / ; 8 � � � � � � 1 � � � � � � � � � � � � N 9 � � � � Y - 1 � 3 � � � � � � � 1 � � � � � � � � � = � � � � 3 � � � � � � 7 � 1 � � � � 2 � � � � � � � � � N � � � � � � � � � � � � � � � � � � � � � > + . / � � � � 9 � � � � � � � 3 � � � � � � � � � 9 � � � 9 � � � � � � � � � � 1 � � � � � 1 � � � � � � � � � � � � � � � � � �� � � � � � r ) - N , , , 1 � � � � � � . ) � � � � � � � � 1 � 1 � � � � � � 1 � � � � � � � � � = � � � Q � 1 + ) / � 3 � � � � � � � � � � � � � � � � � � � � � � 9 � � � � � � � � � 1 � � 1 � 3 9 � � � � 3 � 9 � 1 � � � � � � N � � � � � � � � � � � � 9 � � � � � � � � � 1 � � 1 � 3 � � � � � � � � � N 1 � � � � � � - 3 � � � � � � 1 � 1 � � � � � � 1 � � � � � � � � � = � � � ;. ' ; s � 9 � � � 3 � � � � � 3 � � � 9 � � � � � � � 3 9 � � � � � � 1 � � � � � � � � � � � � � � � � � � 1 � 6 � � � � � � 2 � � � � � � � � � � 1 ? � � � �t 2 � � � � � � � � � � � � � � � � � � � � � 3 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � �� � � � � ;. - ; 8 � � � � � � 1 � N � � � � � � � � � � � � � � � � � � � � � � 1 � � � � � � 1 � � � � � � � � 1 � = � � � � � � � � ( Z � � � ; 2 1 � � � � � � � � �4 � 1 � � � � * ( * N � � � � � � � � � � � � � � � � � � � 9 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3 � � 1 � � � 1 2 � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �+ � � � � � � � � � � � � � � � � > ? ? 9 9 9 ; 1 � ; � � � � ; � � ; � ? � � � � ; � � W u � � � � v ) Z [ ' . / ;. * ; 8 � � � � � � 1 � + � � � � � � � � � � N � � � � � � � � � � 3 N � � � � � � N � � � � � � � � � � � � � � � � � 1 � N � � � � � � � � � � � � � � � � � � 1 � / � � � � � � � � � 3 9 � � � P � 1 � � � � = � � � � � � N � � � 1 � � ' ) 4 P � � � � ' ( Z N � � � � � � � N � � � � � 1 � � � � � � � � � �9 � � � � � � � � � � � � 1 � � � � 1 � � 9 � � � � � � � � � � � � � � � � � � � � � � � 1 � � � 1 � � � � 1 � � � � � � � ;8 � � � � � � � � � � � � 9 � � � � � � � � � � � � � � � � � � 1 � � � � � � � � � � � � � � � � � � � � � � � � � � 1 � � � � 0 � � � � � � � � � � � � � 1 � 2 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � 1 � � � � 2 � � � � � � � � � � ;

] w h b x d l k l _ i l h q k l _ x b e d lAgreement y ^ _ ` a b ` c d e j

L z { | > 8 � � P � � � � � � � � � � � � � � � 3 � � � 1 � � � 1 � � � � � � � 1 � � � � � 1 � � � � � � � � 1 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � N � � � �� � � � � � � � � � � ;� � � � 1 � � � � � � � � >� � � � >� � � � 1 � 5 � � � + � � � P � � � & � � � � 5 � � � / >& � � ' 1 � � � � � � � � � � � � � � � � � � 3 5 � � � � >5 � � � � � � � � � � 1 � � 1 � � � � � � + 5 � � / >] } g g n b d ~ _ ` n � � _ l ^ p } � o k p � h ` e � p j

Page 25: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � ! � " � # � $ % ! � & $ & � $ % # # � & � � ' % $ �

� ( ) * * � + + , - . � � / 0 � 1 , 2 � 3 � 4 5 6 � 7 � � � 7 � � � � � � � 7 � 8 � � � � � � 9 � �� � � � 7 � : 4 � � � � � � : � � � � � � � � � � � � � � � � � � � / � 5 � � � � � � � � 1 � � +

9 � � ; � � � <� � ; < 8 � � � � � <5 � � : <= � � 5 � 7 � <( � � ; � � � <� � � � � � > � � � <� � � � �4 7 7 � < � � � � � <5 � � � : <� � � � 7 � 6 : � � < ; � � . 5 ; 4 ? ( � ; ? � ; � � : 2 <� 4 5 ; 4 ( � ; � ;@ A B C D E F G H C I J H K L F D M M N F C H O D C B P

P A Q M G F E F G J N R B C D E F G H C Q M O D C S N L F D MT U V W X Y W Z [ \ ] ^ _ V W X [ V ` a . 9 � b � � � � � c � b � : 24 � � � � � � � � � � � <d e f g e h i j d k e lm n j f o h e p p q f m r k s h p g t k m k d j u j m f k u m j e k m v w u d f j x u k dh e j m p w v r k e k m q e u k d y j o v h q w e k q u f q e k h o n h z m he k f g h u d { g t k w f k z e j m k u | w j u m n k s h p p k u m f f k s m j h u y

( � � � � ; � � � � . ( � ; ? � ; � � : 2 <I J H K L F D M K } H K ~ D � D S S H M L K1 � � � : � � � � 7 � � � � � � � � � � � � � � � � � � � 9 � � � � 8 � � � � � � � � � � � � � � � � � � � � � �� � � � � � � 7 � � � � � � � � � � � � � � � � � � 7 � � � � � � � 7 � � 7 �+ � � � : � � � � � � � � 7 7 � � � : � � � � � � � � � � � � � � � � � � � 7 � � � �- � 4 � : � � � � � � � : � � � � � 7 � 7 � � � � : � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � 7 � � � � � �) � 4 � : � � � � � � � : � � � � � 7 � 7 � � � � : � � 7 � � � � � � � � � � � � � � � � � � 7 � � � � � � � � �� 7 7 � � � �0 � � � � � : � � � � � � � 7 � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � �� � � � 7 � � : � � � � � � � � � � � � � 7 7 � � � �, � � � � � : � � � � � � � 7 � � � 7 � � � � � 7 � � : � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � 77 � � � �� � � � � � : � � � � � � � � � � � � 7 � � � � � � � � � 7 � : 3 � 7 � � � � � � � � � � � � � � � : � � � � � � � �� � � � 7 � 7 � � � �* � � � � � : � � � � � � � � � � � � 7 � : � � � � � � � � � � � 3 � 7 � � � � 7 � � � � � � � � � � � � � � � 7 � � � � � � � � � � 7 � � � � � � � � � 7 � � � � � � � � � � � � � � � � �� � � � � � : � � � � � � � 7 � � � � � � � � � � � � � ? 7 � � � � � � � � � � � � � � � � 7 � � � � � � � 77 � � � �1 / � � � � � : � � � � � � � 7 � � � � � � � � � � : � � � � � : � � � � � � � � � � 7 � � � � � � : � : � � � 7 7 � � � �1 1 � � � : � � � � � � 0 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � :3 � 7 � � � � 7 � 7 ? � 3 � 7 � � � � � � � � � � � � � � 7 � 7 � � � � � � � 4 7 7 b � � � � � � � � � � � � � � � �1 + � 4 � : � � � � � � � � � � � � � 4 � � � : � � 3 8 � 3 � 7 � � � � 6 � � � � � � � � � � 5 � � 4 � � � � � � �� � � � 7 � � � � � � � � � � : � � � � � � 7 � � � � : � � � � 7 � � � � � � � � 7 � � � � � � � � �� � � � � � � � 7 � � � � � � � � � � � � � � � � 7 � � 7 7 � � � �1 - � 4 � : � � � 3 � 7 � � � � � � � � � � 5 � � 6 � � � ? ( � � � : 5 � � � � : � � � � � � � � � � � � � 7 � � � �� � � � � � � � � : � � � � � � � � � � � � � � � � � 7 � � � � � � � � : � � � � � � � � � � � � � � � � �1 ) � � � � � : � � � � � 7 � � � � � � � � � � � � � � � � � : � � � : � � � � � � � � � � � � � � � � � � � � � � � � � 4 � � � � 7 4 � � � � � � � � � 4 � � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � : � � � � � � � � � � � � � �1 0 � 4 � : � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � � � � � � � � � 4 � � 5 9 � � � � 5 5 �� � � ? � 4 � 4 � � � � ? � � � � � � � ? � 3 � � � � � ? 8 � � � � � ? � � � � � � � � � � � � � � � � � � 4 � � � � � �3 5 b � � � � � � � � > � � � � � � � � � � � 7 �1 , � � : � � � � � � � � � � � � � � � � � � � � � � ( 6 5 � � � � � � � : � � � � � � � � � 7 � � � � � � � 7 � � � 4 > 8� � � � 7 � � � � � � � � � � � � � � � � � � 7 � � � 7 � � � � � � � � � � � � � � � � � : � � � � 7 � � � � � � � � � � � � �: � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � � �

Page 26: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � ! � " � # � $ % ! � & $ & � $ % # # � & � � ' % $ �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

� � � � + � � +� ( ) * * � + + , - . � � / 0 � 1 , 2 � 3 � 4 5 6 � 7 � � � 7 � � � � � � � 7 � 8 � � � � � � 9 � �� � � � 7 � : 4 � � � � � � : � � � � � � � � � � � � � � � � � � � / � 5 � � � �

I J H K L F D M K } H K ~ D � D S S H M L K1 � � � : � � � � 7 � � � � � � � � � � � � � � � � � � � 9 � � � � 8 � � � � � � � � � � � � � � � � � � � � � �� � � � � � � 7 � � � � � � � � � � � � � � � � � � 7 � � � � � � � 7 � � 7 �+ � � � : � � � � � � � � 7 7 � � � : � � � � � � � � � � � � � � � � � � � 7 � � � �- � 4 � : � � � � � � � : � � � � � 7 � 7 � � � � : � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � 7 � � � � � �) � 4 � : � � � � � � � : � � � � � 7 � 7 � � � � : � � 7 � � � � � � � � � � � � � � � � � � 7 � � � � � � � � �� 7 7 � � � �0 � � � � � : � � � � � � � 7 � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � �� � � � 7 � � : � � � � � � � � � � � � � 7 7 � � � �, � � � � � : � � � � � � � 7 � � � 7 � � � � � 7 � � : � � � � � � � � � � � � � � � � � � � � � � � 7 � � � � � 77 � � � �� � � � � � : � � � � � � � � � � � � 7 � � � � � � � � � 7 � : 3 � 7 � � � � � � � � � � � � � � � : � � � � � � � �� � � � 7 � 7 � � � �* � � � � � : � � � � � � � � � � � � 7 � : � � � � � � � � � � � 3 � 7 � � � � 7 � � � � � � � � � � � � � � � 7 � � � � � � � � � � 7 � � � � � � � � � 7 � � � � � � � � � � � � � � � � �� � � � � � : � � � � � � � 7 � � � � � � � � � � � � � ? 7 � � � � � � � � � � � � � � � � 7 � � � � � � � 77 � � � �1 / � � � � � : � � � � � � � 7 � � � � � � � � � � : � � � � � : � � � � � � � � � � 7 � � � � � � : � : � � � 7 7 � � � �1 1 � � � : � � � � � � 0 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � :3 � 7 � � � � 7 � 7 ? � 3 � 7 � � � � � � � � � � � � � � 7 � 7 � � � � � � � 4 7 7 b � � � � � � � � � � � � � � � �1 + � � � � � : � � � � 7 � : � � � � � � � � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � � � � � � � � � 7 �7 � � � � � � � � � � 7 7 � � � �1 - � 4 � : � � � � � � � � � � � � � 4 � � � : � � 3 8 � 3 � 7 � � � � 6 � � � � � � � � � � 5 � � 4 � � � � � � �� � � � 7 � � � � � � � � � � : � � � � � � 7 � � � � : � � � � 7 � � � � � � � � 7 � � � � � � � � �� � � � � � � � 7 � � � � � � � � � � � � � � � � 7 � � 7 7 � � � �1 ) � 4 � : � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � � � � � � � � � 4 � � 5 9 � � � � 5 5 �� � � ? � 4 � 4 � � � � ? � � � � � � � ? � 3 � � � � � ? 8 � � � � � ? � � � � � � � � � � � � � � � � � � 4 � � � � � �3 5 b � � � � � � � � > � � � � � � � � � � � 7 �1 0 � 4 � : � � � 4 � ; . 5 � � � � � � 7 � ; 4 � � � � � � � � ; � � 3 � 7 � � � � � 5 � � � � � � ; � � � � � � � � � �; � � � � � � � � � � � 2 � � � : � � � � 4 � � � � � � 7 7 � : � � � � � � � 5 � � � � � � � � � � �4 � � � � � � � � � � � � � � � � 7 � ; � � . 2 � � � � � � � � � � � � � � � � � 7 � �1 , � 4 � : � � � ; � � 3 � 7 � � � � � � � � � � � � � � � � � 7 � � � � � � � 7 ? � 7 � � � � � : � � � � � � � � � � � � � �� � � � � � � 7 � 7 7 � � � � � � � � � � � � � � � �1 � � 4 � : � � � 5 � � � � � � 7 � � � � � � � 7 ; � � 4 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � 7 � 7 7 � � � � � � � � � � � � � � � � � � � � : � � � � � � � � � �1 * � � 5 � � � 7 ? 4 7 � � � � � � � : � � � � � : � � � 7 � � : � � � � � � � : � � � � � : � � � 7 � � : : � � � � � � � � � � � : � � � � � � � � � � � � � � � � � � � : � � � : � � � � � � � � � 7 � � : � 7 � : � � . 2 �1 � � 4 � : � � � � 7 � � � � � � � � � � � � � � � . � � � � � � � � � 2 � � � � � � � 5 � � � � � 7 � � � 7 � �� � � � � � � � 6 � � � � 9 � � � � � � : � � 7 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � > � � �5 � � � � � � � � � : � � � � � � � � � � � �+ / � 4 � : � � � � � : � � � � � � � � � � � � � 9 � � 5 � 8 � 5 � 3 � 7 � � � � � 5 � � � � � � � 5 � � � � � � � � � � �4 � � � : � 5 � � � � � � : � � � � � � 4 � � � : � 5 � � � � � � 7 � � � � � � � � � � � � � � � � � � > � � 7 ? ( � � � 75 � � � � � � 7 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3 � 8 � � � � � �+ 1 � : � � � � � � � � � � � � � � � � � � � � � � ( 6 5 � � � � � � � : � � � � � � � � � 7 � � � � � � � 7 � � � 4 > 8� � � � 7 � � � � � � � � � � � � � � � � � � 7 � � � 7 � � � � � � � � � � � � � � � � � : � � � � 7 � � � � � � � � � � � � �: � � � � � � � � � � � � � � 7 � � � � � � � � � � � � � � � � �+ + � 4 � : � � � � � � � 7 � � � � � � � � � � � 7 9 � � � � : � � � � � � � � � 7 � ? 5 � � � � � � � � � � � � � � �� � � � 7 � � � � � � � � 7 � � � � 7 � � � � � � � � � � � : �+ - � 4 � : � � � � � � � 7 � � � � � � � � � � � � 5 � � � 7 � � � � � � . � 9 5 2 � 7 � � � � � � � � � � � � : ? � � � � � � � � � : � � � � � � � b > � � � ; � b > ? � � ; � � � � � � � � � � 7 � � � � � � � � 7 � � � �

� A B C D E F G H C I J H K L F D M M N F C H O D C � ~ P � � B ~ � � ~

Page 27: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � ! " # $ $ % � � & � � � � � � ' � ( � � � � � � ) � � � � � ! $ * � % + � � � � � + � & � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! , , , % + � - � � � � � � � & & � � � � � � � . � � � � � � � � / 0 � � 1 0 � � 1 ) � � � ( � � � � � � � + � � � � � 2 � � � � � � � � ( � �2 � � � � � ) � � � � � � ( � � � � � � � � � � � 3 � � � � � � � � � � . 2 � � � � � � � � � 4 � � � � � �

Page 28: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 29: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

�� � � � � � � � � � � � �

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! � � ! � � " ! � # $ � � � � � � � � % � & ' � � � � � � � � � � �� � � � � � ( � � � � # � � � ) � # � � � � � � * � � � ! � � � + � � � � � � � � # � � � � � � & � � � # � � � ,- . / 0 1 2 - 3 4 - 5 - 4 6 0 7 / 8 9 5 - 4 : 8 : 3 8 9 7 7 . : 3 2 ; 9 8 . < - 7 = > > ? @ @ A B CØ

0 7 7 D E F G H G F I J K L M N H G F O M P J M O M O Q I G M O F R N S N T U K O R O V O S R G N E W N X R Y O D Z L W [ \ D E F G H G F I J K L M N H G F O M] E M N K K T O E R ^ N M TØ

/ _ ` a b c d e 0 a a f a g d c g a J M O M O Q I G M O F R N S N T U K O R O V O S R G N E W h i N X R Y O D Z L W [ \ D E F G H G F I J K L M N H G F O M] E M N K K T O E R ^ N M TØ

1 3 0 a j 7 / 3 a d c k 8 3 a J M O M O Q I G M O F R N S N T U K O R O V O S R G N E W h [ N X R Y O D Z L W [ \ D E F G H G F I J K L M N H G F O M] E M N K K T O E R ^ N M TØ

D X l N I J M O J E D E F G H G F I J K L M N H G F O M m Y N U M N H G F O P T N M O R Y J E N E O P O M H G S O R l U O n U K O J P O P O K O S R l N I MY G o Y O P R F G P S G U K G E O p( q r s � � � � � � & � � � � ' * & t $ � � � � � � � � � � � � � � � u � � � # � � � � � � � ! � # $ � � � � � � � � � # v � � � � � � � � �� � � � � � � � � � ! � $ � � � � � � � � ! � � � ,Ø w L x P J E F y x P T I P R U M N H G F O J H J K G F w G S O E P O x I T z O M R N P Y N m R Y O l J M O S O M R G X G O F pØ

x L D { x J R G N E J K L M N H G F O M D F O E R G X G O M | G P M O Q I G M O F X N M J K K [ x W } n w L x J E F y x P R N z O O E M N K K O F G E R Y O D Z L W [ \V l P R O T p ~ 3 9 2 : � W x L D � � � � � � � � G P N U R G N E J K J R R Y G P R G T O J E F N E K l M O Q I G M O F G X l N I S I M M O E R K l Y J H O N E O pØ

D X l N I F N E N R Y J H O J E x L D � U K O J P O N z R J G E N E O J R Y R R U P � � � E U U O P p S T P p Y Y P p o N H N M H G P G RY R R U � � � F M P p G K K G E N G P p o N H � Y P U � G T U J S R R N X G E F N I R Y N m R N N z R J G E J E x L D p- . / 0 1 2 � 0 - 5 : 8 / 8 9 � 8 0 . / 8 9 5 - 4 : 8 0 � 8 : : . : 3 2 < - 7 = > > ? @ @ A @ CØ

0 7 7 D E F G H G F I J K L M N H G F O M P T I P R U M G E R X I K K K O o J K E J T O n K J P R � F G o G R P N X V V x n P G o E J E F F J R O D w � � � � � � � � pØ

[ x W P } n w L x P n J E F y x P T I P R J K P N G E S K I F O R Y O G M x L D E I T z O M p/ _ ` a b c d e 0 a a f a g d c g < / 0 C �W � D E F G H G F I J K L M N H G F O M D E X N M T J R G N E� � � � � � ! � # $ � � � � � � � � � " � � v � � � ! � � � � # � � � � � � � � � ! � � � � & ,� � � � � � � & � � � � � � � � � ! � � � � � � � � � � � � � � � � � � � v � � � � rJ p W U U K G S J R G N E D � � ) � � � � � ! � � � � � � � " �z p w G S O E P O x I T z O M � ) � � � * � � * � � � " �S p x L D � ) � ' * & } � � � * � � * � � � " �i � L M N H G F O M � I O P R G N E E J G M O X N M L W� � � � � � � � $ � � � � � � � � � � u � � � � � � � � � � � � ! � � � � � ,� � " � � � � � � � � � � � � � � � � � � � � � � � " � � � � � u � � � � � � � � t $ � � � � � � � $ � � � � � � � * � & � � � � ' � # # � � � � ,[ � L M N H G F O M � I O P R G N E E J G M O X N M [ x W � w L x � y x� � � $ � � ! � � � � ' ,

Page 30: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

�� � � � � � � � � � � � �

1 3 0 �W � D E F G H G F I J K L M N H G F O M D E X N M T J R G N E� � � � � � ! � # $ � � � � � � � � � " � � v � � � ! � � � � # � � � � � � � � � ! � � � � & ,' * & � ! � � � � � � � � � � � � � � � � � � � v � � � � rJ p W U U K G S J R G N E D � � ) � � � � � ! � � � � � � � " �z p w G S O E P O x I T z O M � ) � � � * � � * � � � " �i � L M N H G F O M � I O P R G N E E J G M O X N M L W� � � $ � � ! � � � � � ,[ � L M N H G F O M � I O P R G N E E J G M O X N M [ x W � w L x � y x� � � � � � � � $ � � � � � � � �   ¡ u � � � � � � � � � � � � ! � � � � ' ,� � " � � � � � � � � � � � � � � � � � � � � � � � " � � � � � u � � � � � � � � t $ � � � � � � � $ � � � � � � � * � & � � � � ' � # # � � � � ,7 / 3 ¢ 8 3 �W � D E F G H G F I J K L M N H G F O D E X N M T J R G N E� � � � � � ! � # $ � � � � � � � � � " � � v � � � � � � � � # � � � � � � � � � ! � � � � & ,� � * � � * ! � � � � � � � � � � � � � � � � � � � v � � � � rJ p W U U K G S J R G N E D � � ) � � � � � ! � � � � � � � " �i � L M N H G F O M � I O P R G N E E J G M O X N M L W� � � $ � � ! � � � � � ,[ � L M N H G F O M � I O P R G N E E J G M O X N M [ x W � w L x � y x� � � � � � � � $ � � � � � � � �   ¡ u � � � � � � � � � � � � ! � � � � ' ,� � " � � � � � � � � � � � � � � � � � � � � � � � " � � � � � u � � � � � � � � t $ � � � � � � � $ � � � � � � � * � & � � � � ' � # # � � � � ,/ 7 : 0 £ : 3 9 2 : �x J R G N E J K L M N H G F O M D F O E R G X G O M { x L D | �D X l N I J M O J [ x W } � w L x � y x J U U K l G E o X N M J x L D E I T z O M n R Y O N E K G E O J U U K G S J R G N E J RY R R U P � � � E U U O P p S T P p Y Y P p o N H m G K K M O Q I G M O R Y O O E R M l N X \ J ¤ N E N T l [ N F O R N U M N S O P P l N I M M O Q I O P R p \ Y OX N K K N m G E o \ J ¤ N E N T l [ N F O P J M O M O S N T T O E F O F z J P O F N E l N I M L M N H G F O M \ l U O �[ x W � ¥ ¦ � § ¨ ¨ ¨ ¨ ¨ ©w L x � � � � ª ¨ ¨ ¨ ¨ ¨ ©y x � � � ¥ ª ¨ ¨ ¨ ¨ ¨ ©~ 3 9 2 : � W x L D G P � « ¬ ­ � ® ¯ ° � � � � � � � � ¯ ¬ ¬ Y G P R G T O J E F N E K l M O Q I G M O F G X l N I S I M M O E R K l Y J H O N E O p

Page 31: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! � � " � � � ! � � # � � � �

� � � � � � � � � � � � !$ � � � � % � � � � & � % � � � � � ' ! � $ � � � ! � � � � � � � � � � � � � � � � � � � � ' ! � & � % � � � ' ! � � � # � � %� � � � � � � � � ( � � ) � � � � � � � � � � � � % � ! � � ' � % � � � � ( � � � � � � � � � � � ! � � � � � � � * � � � ! ' � � � � � & � � � � ! � � � � � � � � � � � � �� � � � ' � � � � + � � � ' � % � � � � � � � � � � ( � � # , � ! � � � � ! � � � � � - � � % � � � � % % � � � � � � � � � $ & � $ + & � � � � � � � � � � � � ! + � � � � �. � � � � � � * / * + � * 0 * 1 � - � � � � � + � � � � # � � � � + � � 2 � 3 � � � � � � � + � � � � 3 4 5 5 3 � � � � � � 6 � - � *� � � � � � � � � � � � � � � � � ! ( � � � � � � � � � � � � � � � � % � � � ( � � ) � � � � � � # � ' � ! � � � � � � � � � � � � � � � � � � � � � � � � % � � � � � *7 � � ! � � � % ' � � � ! � � � � � � ! � � � � � ! ! � ! � � � � ! + � � � � � � $ � � � " � � � � � � 8 � � ! � � � ! + � � � � � � $ � � � � � ' � ! � � � � ' � � ' � � 8 � � ! ! + � � � � � � $ � � � # � ! � � � 8 � � ! ! + � � � � � � $ � � � � � � ! � ' � � 7 � � � � � ! � ! + � � � � � � $ � � � 0 ' ' � � � � � � � � � 7 � � � � � ! � ! + � � � � � � � � � $ � � � � ' �7 � � � � � ! � ! ( � � � � � � � � � � � � � # � � � & � % � � � ' ! � � � # � � % *� 9 0 : ; : 7 " 0 ; � � / 7 / � � � < : / 7 � 0 8 �� * 8 � % � � � � � � � � � � � � � � � � � � � � � ( � � ( � ! � � � � � � =� * � � � � ! ! � � � � � � � � � � � � � � � � � � � � � =� * $ � � � � � � � � � = � ' � � � ' � � � � � 8 � % � � =� * � � � � 8 � % � � � � � � � � � � � � � � � � � � � � � =5 * � � ' � � � � � � � � � � � � ! ! ( � � � � � � � � � � � ' ' � � � � =2 * $ ! ' � � � � � ( � � � � � � � � � ' ' � � � � =3 * / - � � � � � � � � � � � � � � � � � � ! � ! � � � � � =

� * > � ! � � � � � � � � ! � ( � � ) � � % ? 9 ! 8 � � � ! � + ( � � � � � � � � � ! � % ( � � ) ?� * $ � � � � � � � � � � � � =� * 7 � % � � � � � � � � � � =� � * 8 � % � � � & � ' � ! � � % � � � � ' � ! � � % � ! � � � � � � � % � � � � ' � � � � =� � � � � � 8 � % � � � � ! � � � � � � � � # � � � � � � � � � # � � � � � � � � � ! � � � � � � � � # � � � � � � � � $ � �

Page 32: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 33: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! " � # � � � $ � � � � % & 'wv

|

{

z

y

x

u

( ) ) * + , ) - . / , 0 1 + / , - 2 3 4 ,5 3 6 7 ) , 2 , - + 8 3 / - , / * 3 /2 + 6 , . 9 , , 2 2 3 4 , 7 / 3 5 , . . , - :u ; < = > ? = @ > = @ ? > > A B C B = A B D = ? B E =< F G H > ?v ; < = > ? I J D > K F G H > ? LI F D = M G > ? K J G > L N A A ? > D D LO B P I M A > L J < A E F ? ? > < = Q @ M < >K F G H > ? R S J ? T = @ > H M U B V = @ B DB < V M ? G J = B M < @ J D E @ J < C > A Rw ; < = > ? W M ? T > ? X X K L W M ? T > ?K J G > L N A A ? > D D L O B P I M A > J < AE F ? ? > < = Q @ M < > R S J ? T = @ > H M UB V = @ > B < V M ? G J = B M < @ J DE @ J < C > Ax ; < = > ? = @ > G M < = @ J < A = @ >Y > J ? = @ J = = @ > D > ? Z B E > [ J DP ? M Z B A > A Ry \ V Y M F J ? > [ M ? T B < C J DD M G > = @ B < C M = @ > ? = @ J < J Q R N R LP ] > J D > E @ > E T = @ > H M U Rz ^ B D = = @ > > U J E = = B G > P ? M Z B A > A= M Y M F Z B J = @ > ; _ _ D Y D = > G R` M K a b ? M F < A c{W M ? T > ? X B C < J = F ? > J < A ` J = >|I F D = M G > ? X B C < J = F ? > J < A ` J = >d e f g h i f d j k l m

· n � ! � � � � � o � � � � ! " � � # p � � q ! � � � r & � � s t t # & # � � " u· v � � # ! � � � $ # ! � w � ! w % ! w � � � � � � � � � � � � w � # ! � � � � � � # # � � � � � � � x p � & u· y # � r % � � z � � r % $ � ! � z u· v � " p % � � � � � � ! " � # � � � ! � x $ % % { x � ! % $ � � � � � � # � " � & � � % � & p � & " � � � u| } } ~ � � k e � i � � e � m� 8 � ) + . 9� � � � � � � � � � � � � �� � � � � � � � � � � � � � � 7 � 8 + . 9� � � � � � � � � � � � � �� � � � � � � � � � � � � � � 1 ) 2 + 7 ) , � 1 . 2 3 6 , / . + 8 � 3 6 ,� � � � � � � � � � � � � �� � � � � � � � � � � � � �

  ¡ ¢ £ ¤ ¥ � ¡ � ¢ ¦ § ¤ ¨ �v � % % � ! # � $ " r � �© ª « ¬ ­ x � � ! � x � � " � � ! � �� r � $ � & � $ � � � � z # u� � � � � � � � � � � � � �« � q � � � � � � � �

Page 34: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 35: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� � � � � �

Page 36: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 37: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Home Services Program Individual Provider Payroll Schedule 2020

Pay Period Time Sheets Due PA Hotline Pay Date

December 16-31, 2019 January 1 - 8 January 15 January 28

January 1-15 January 16 - 23 January 30 February 13

January 16-31 February 1 - 7 February 14 February 28

February 1-15 February 16 - 25 February 28 March 13

February 16-28 March 1- 7 * March 13 March 27

March 1-15 March 16 - 22 March 31 April 13

March 16-31 April 1 - 7 April 15 April 28

April 1-15 April 16 - 22 April 30 May 13

April 16-30 May 1 - 7 May 14 May 28

May 1-15 May 16 - 22 May 29 June 12

May 16-31 June 1 - 7 * June 15 June 26

June 1-15 June 16 - 22 June 29 July 13

June 16-30 July 1 - 8 July 15 July 28

July 1-15 July 16 - 22 July 31 August 13

July 16-31 August 1 - 7 August 14 August 28

August 1-15 August 16 - 22 * August 28 September 11

August 16-31 September 1 - 9 September 15 September 28

September 1-15 September 16 - 22 September 30 October 13

September 16-30 October 1 - 7 October 15 October 28

October 1-15 October 16 - 22 October 29 November 13

October 16-31 November 1 - 7 * November 12 November 25

November 1-15 November 16 - 22 * November 30 December 11

November 16-30 December 1 - 7 December 10 December 23

December 1-15 December 16 - 22 December 30 January 13

December 16-31 January 1 - 8, 2021 January 14 January 28

*Timesheet due date falls on a weekend.Please ensure timesheets are signed anddelivered prior to the stated deadline toguarantee timely payment.

Provider Assistance Hotline: 1-800-804-3833 or1-877-434-1082 (TTY)

Page 38: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 39: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

� ����� ���� � �� � �� ������� ���� ��� ����� ���

��� �� ����� ���� �� � ��� ��� ��� ������ �� ���

�� � ������ ����� �� �� ����

��� ����������� �� �� �

� ! "#$%&

' ()*+,-)+,..)++/ ,0 +1)23 )-

4)-5/5 .265 (* 7/ (00 (869 )+),+)/ ,0 65 1+:

;< ��= � �� ������ ������ �� �� ���

�� ����� ����� �� �� ����> ���

;< ��= � �� �������� ��� �� ���� �

� ��� ��?�� �@ ��A ���B� ���= �C ��� ���

; � �� �� � �� �� ������� �;

'9 )+)2-)+(D)1(++5E0 )1-(E0 )D+F(,

D2F)G1)-5 )*.)89 )*,+5 *H69 )

6 )0 )19 (*) I J K#LMN O"PQR STU %VW XU %"KYZ %&X YPW %#K&%

L KU P[%XU %&N OU X \U "%"KYZ %& S

] S^ &LVPQQN "OPOPN " S_ S^ &LVPQQN "OXU %#%V "` X QQ ab &%%

"KYZ %&\& [N %` b XU %b & "X \PO%

b XUN #OKN % Sc Sdb L K#XNQQ VP"" X V Y\Q %X %XU %VPQQ e

fQ %P#%VPQQ XU %ghMijjh %Q \kN "%

PXRlllmR_nR_o S

db XU %#L#X %Y#PL#pqr (--F 7s *4205t

u ,DE )-v M %%Nb XU %\U "%U P#P' awx "% aX a

\KQ #%y #$N X VU zYPW %#K&%XU %#$N X VU

N # "' Sdb XU %&%N #" #$N X VU eL K

YK#X #PLL K&dg "KYZ %& "%N ON X PX

PXN Y% eN "X XU %\U "%Pb X %&XU %

X "% S

{ &N X %L K&M P"X &P|dg "KYZ %&PZ [%

b &%P#L&%b %&%"V% S

Page 40: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

} ~�� � ��� ~�� �~���� ������ �� ���� ���� ���� ��

�� ����� ����� �� ��� ���� ��������� ����� �

� ��� ��� ��� �� ������ ���} ~�� � ���  �

·

¡ ���¢ ��� ��£¤¥ ¦} ~�� � ��§© �

·

¡ ���¢ ��� ��£¤¥ ¦

ª «¬� ~� ~�­®¯ �° ±� ®�� ²¯ �±±�³µ ±�¶

� ®·~� ±¸ ®��° ±¯ �®�� ¹~�±®¯ �° � ¶�³�¸ ± «

¢ ��� ��£���� ����º » ¼½ ¾¿À¼ Á½ ¼Ãļ

±�� ±�­®³�� ~�� �~��¬ ÅÆÇÈ ÉÊËÌÍÎÎÏÐ

ÎÍÑ ÎÒÓÑ ÒÔÕÑÈÈÑ ÓËÖ ×Ñ ÎØÙÑ ×Ú ×Ú Î

ÈÑ ÍØ×× ÊÖÖ ÛÈ ÍÎÎÒËÜÝ ÎÍ ÞÐÖ ÎÌØÎËØÎ×Ú ÎØÎÓÊÒÕ

× ÊÖÖ ÛÈ ÍÎÎÒËÜÝ ÎÍ ßà áâ �±¶¶�° ±�³µ ±�¶®¯ ­®³�� ~�� �~��¬

®��° ±� ®³·° � ®�±¹° ®�± ᢠ��� ��£���� ����º ã ¿ä¼åæç èè¿éå

�¸ ±���� ­ ê¹� ±~¶±�±¹±~� �ë�� ~�� �~� ê­

ì®� ·±� ¶­¹~¶¶í®�¸ «Æ

îïðñ òÇÈ ÉÊËÚ ÌóÎÒÊ×Ý ÎÎÒÎÒÍÊÖÖ ÎÕÑ Òô ÐÎÌõ ÎÍ

ö ÎÍÑÈÑ ÓÌ×Ñ ÊÒ Þô ÌÒ× ÍÌÏÙÑÖÖ ØõÑ Ð×ÚÑ Ø

ÐÍÊÜÐ× ßÇÈ ×ÚÑ ØÑ Ø×Ú ÎÓÌØÎ ÞØõÑ ÐØ× ÎÐ÷ Þ

ÌÒÕ ×Ú ÎÒÓÊÒ×Ñ ÒËÎÙÑ ×Ú ×Ú ÎÒÎÏ× ÐÍÊÜÐ× ß

ø «ù Ãèº úûù Ãüû åÃý ÁÀèä¿æ ¾¼æ ÄÀè

ÂÃÄÄþ¿åÿÆ �Ú Îô ÌÒ× ÍÌÏØÉØ× ÎÜÜÌÉÌØõ ÉÊË× ÊÍÎÐÎÌ×

×Ú ÎÐÚ ÍÌØÎØÎóÎÍÌÖ ×Ñ ÜÎØÝ ÎÈ ÊÍÎóÎÍÑÈ ÉÑ ÒÔ

ÉÊËÍÑÕ ÎÒ×Ñ × É ß

¢ ��� ��£���� ����º �ç û� æ Äæ ÄÃ�æ ý¼ÿ �æ Äæû

� ±��¯ � ·~�� ®�ì� ¶�� ³¶� ���° ±���¸ ±ì� ·± ê

¹�±¶¶�° ±¶� ~��� ±­� ®±�� ±��° ±ì� ¶��

ì±��¯ � ·~�� ®��³µ ±�¶ «§�° ±�í� ¶± ê¹�±¶¶

�° ±¹®³�� � ±­� ®·®��� �³± «Æ

ÇÈ ×ÚÑ ØÑ ØÌÒ�öö ÌÖÖ ÞÐÍÎØØ×Ú ÎØ× ÌÍ���õ ÎÉ

ÌÒÕ ÍÎÈ ÎÍ× Ê×Ú Î�öö ÌÖÖ� ÎÈ ÎÍÎÒÓÎ� ËÑÕ Î

È ÊÍÕ Î× ÌÑÖ ÎÕÑ ÒØ× ÍËÓ×Ñ ÊÒÈ ÊÍ×Ú Î�öö ÓÌÖÖ

ÐÍÊÓÎØØ ßÇÈ ×ÚÑ ØÑ ØÒÊ× ÌÒ�öö ÓÌÖÖ ÞÐÍÎØØ

ÐÊËÒÕ��� ÌÒÕ ÓÊÒ×Ñ ÒËÎ ß� «â �±¶¶�° ±¹®³�� � ±­� ®·®��� �³± «

¢ ��� ��£���� ����º �½ ¼Ãļļ½ ¼¾ûº �Æ û ¿

·~�� � �®�� �� � ®·~�� ®³� «�� «â �±¶¶�° ±®�±� ª ±­� ®� } ~�� � �� «

§ � â �±¶¶�° ±� í®� � ±­� ®� } ~�� § ³�� «

¢ ��� ��£���� ����º � ¼¾¼æ ä¼ÿ Ãû� ã���� Å

� �� ±��³µ ±�®¯ � ~¶ ¶ «�îïðñ òÇÈ ÉÊËÌÍÎÐÖ ÌÓÑ ÒÔ×Ú ÎÑ ÒÓÌÖÖ Þ

!î"#$îï% á

� ÌØõ ØÌÍÎÊÒÖ ÉÎÒ× ÎÍÎÕ ÊÒ×Ú ÎÊË× ÓÌÖÖ ß& «â �±¶¶®�±� ª � ®� �¸ � ·~� ±­®³í���µ ±

±�� ±�� ��®�±� ~¶ «¢ ��� ��£���� ��� �º � üû ¼åû ÃÄ' �(Æ

) «â �±¶¶�° ±© ~¶   ³µ ±�­®³

¹±�¯ ®�±¸ « îïðñ* ò·

� ÎÈ ÎÍ× ÊÉÊËÍð +,- . /0 /1/23/45 +16Ý ÎÖ ÊÙ ß

·

ÇÈ ÉÊËÜÌÕ ÎÌÜÑ Ø× Ìõ ÎÎÒ× ÎÍÑ ÒÔ×Ú Î× ÌØõ Þ

789::;<<= >?@ 9:A:? 9BCDEE FGHID 8BJ A

ØÌÉÑ ÒÔ Kº ùû Ãåûæ üLM ä¼å Á� �� ±��³µ ±�®¯

û ÃÄ' ÄÆ á ¢ ��� ��£���� ����º N ¿é¼üû ¼å¼ÿ ®�±

û ÃÄ' ÅÆ O «P ~��³¹ « © ~¶ �¬ QQ QR QS QT¬ ±¶·�� ¹�� ®�

UVW XYV Y ������� W ��� �� ���ZV

Page 41: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

STATE OF ILLINOIS

C-95A 1 /201

!

___/ ___/ ___/ ___/ ___/ ___/ ___/ ___/ ___/ Social Security Number (Taxpayer Identification Number) (Please type or print in ink)

__________________________________________________ ________________________________________________ Payee's Name Name of Program Agency

______________________________________________________________________________________________________ Payee Mailing Address (Apt/P.O. Box) City State Zip Code

!

I, _________________________________, certify the information provided on this form is correct. I authorize and Type/Print Payee Name

request the program agency to direct my recurring payments for crediting in my account at the financial institution

designated below and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my

account. If a direct deposit cannot be made, I understand that the program agency shall provide payment to me by

paper warrant. This authorization is not an assignment of my right to receive payment and revokes all prior payment

direction notifications applicable to these payments. I understand that the financial institution designated reserves the

right to cancel this agreement by notice to me.

"""""""""""""""""""""""""""""""""""""""""""""""""!!!!!!!!"""""""!!!!!!!!"""""""""""""""""""""""""""""""""""!Signature of Payee Date Work Area Code and Telephone Number !

- - - - - - Financial Institution Information - - - - - -

NOTE: It is recommended that you contact your financial institution to verify your correct transit routing and account

numbers. Any errors in these numbers will cause direct deposits to be returned and replaced with paper warrants

through the program agency.

__________________________________________________________ ( __/ __/ __ ) __/ __/ __/ #!__/ __/ __/ __/ Name of Financial Institution Financial Institution Area Code and Telephone Number

______________________________________________________________________________________________

Branch Address, City, State, Zip Code

__/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/

Financial Institution Routing Number Payee Account Number !

You must select one of the following options: ! Direct deposit to my CHECKING account.

! Direct deposit to my SAVINGS account.

Official Use Only

______________ __/ __/ __/ __/ __/ __/ __/ __/ __/ - __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/ __/

Agency Number Verification of Routing Number Verification of Payee Account Number

To apply for direct deposit of State of Illinois payroll payments, complete this form,

sign and return it to your agency's Payroll Department along with a voided check.!

Authorization for Deposit of Recurring Payments

Page 42: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

SCO-95A

STATE OF ILLINOIS

IMPORTANT NOTICE: This form is to be used only for State of Illinois Recurring Payments.

If you wish your payments sent to your financial institution for deposit into your savings or checking account, you

must complete this form to authorize this action. Some agencies may require your financial institution to verify

routing and account information. The State Comptroller will forward your recurring payments to the destination you|

authorize. The financial institution may be any bank, savings bank, savings and loan association or similar institution,

or Federal-or state-chartered credit union that is a member of the Automated Clearing House Access Program. If you

do not have an account at such a facility, you must contact a qualifying financial institution and establish an account

prior to enrolling for direct deposit.

INSTRUCTIONS

Please type or print in ink all information requested.

1. Type or print the payee's Social Security Number. Do not include dashes.

2. Type or print the name of the person to whom the payment is made. This is the Payee Name except where arepresentative payee has been appointed or a guardian or conservator has been appointed by a Court.

3. Type or print the Name of Program Agency.

4. Type/Print Payee Name in the space provided, sign where indicated (Signature of Payee) and print Date.

5. Type or print the Work Area Code and Telephone Number of the payee or a number where the payee can bereached during the day.

6. Type or print the Name of Financial Institution in which the payee's account resides.

7. Type or print the Financial Institution Area Code and Telephone Number.

8. Type or print the financial institution Branch Address, City, State, Zip Code where the payee's account resides.

9. Type or print the 9-digit Financial Institution Routing Number that appears at the bottom of the payee's printedchecks. (The program agency may require the payee to have this information verified by the financial institutionprior to submitting the authorization form.)

10. Type or print the Payee Account Number that also appears at the bottom of the payee's printed checks. Thenumber of digits varies among institutions.

11. You must select one account type to receive recurring payments (Checking or Savings). Payee must indicatewhich one of his accounts (Savings or Checking) should receive the recurring direct deposits.

12. Attach a voided check before submitting this completed form to your agency's payroll clerk. Do not substitute adeposit slip for the voided check. Financial institutions may alter numbers that appear on deposit slips for internalpurposes.

CANCELLATION INSTRUCTIONS

When entered in the payee's record with the program agency, this authorization will remain in effect until canceled by notice to the

program agency by the payee or in the event of death of the payee or the beneficiary of this payment. The financial institution

should also be notified if the payee cancels this agreement. The financial institution may cancel their agreement by providing the

payee with a written notice 30 days in advance of the cancellation date. The payee must advise the program agency immediately if

this authorization is cancelled. The financial institution cannot cancel this authorization by advice to the program agency.

Privacy Act Notice: You previously provided your Taxpayer Identification Number (TIN), i.e. your social security number or your employer identification number, to

the State of Illinois upon becoming a State of Illinois payee. Section 6109 of the Internal Revenue Code requires you to give your correct TIN to

persons, such as the State of Illinois Office of the Comptroller, who must file documents with the Internal Revenue Service to report income paid

to you, the acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. The Illinois Office of the

Comptroller, as administrator of the direct deposit program, requests verification of your TIN on the Authorization for Deposit of Recurring

Payments. Your TIN verification enables proper payee identification and corresponding direction of payments as specified on your completed

Authorization for Deposit of Recurring Payments. While not mandatory, failure to provide your TIN on the Authorization precludes your

participation in the direct deposit program.

Page 43: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Illinois Debit MasterCard Payment Option Form

State of Illinois - Department of Human Services

IL444-0800 (R-6-10) Page 1 of 1

If you chose the Illinois Debit MasterCard Card, we will update our records and you will receive your Illinois Debit MasterCard in the mail. Activate your card

immediately by calling the toll free number (1-866-338-2944) and follow the instruction on the materials enclosed with your card. Make sure we

have your correct address.

Your card will not be forwarded.

In order to get a Illinois Debit MasterCard:

* Attach a copy of your current Driver's License or State I.D. card

* You MUST fill in all the blanks in the section you are completing (Section 1 to start card use, section 2 to stop card use. )

* All information must be clear and readable

* Once you choose the Illinois Debit MasterCard your payments will continue on the card until a written cancellation Payment

Option Form is received and processed at DHS.* You MUST send the form to:

Department of Human Services

Bureau of Expenditure Accounting Debit Card Project

100 South Grand Ave. East, 1st Floor

Springfield, Illinois 62762

Illinois Debit MasterCard Card Payment Option - All blanks in this section below MUST be completed®

I authorize the State of Illinois Office of the Comptroller to direct payment for deposit to the Illinois Debit MasterCard card account as

directed by the paying State agency. I understand the card will be sent to me by mail and my payments will be held by the bank until I

withdraw them using my Illinois Debit MasterCard card. I further authorize the Comptroller to initiate, if necessary, debit entries and

adjustments for any credit entries in error. This authorization is applicable to all Child Care and Personal Assistants payments issued by

the Comptroller to the below named payee as identified by its designated payee identification number.

I understand the Illinois Debit MasterCard is issued by Comerica Bank, pursuant to a license by MasterCard International Incorporated. I

further certify that I am at least 18 years of age.

Daytime Phone:Social Security Number:

Last Name: First Name: Middle Initial:

Mailing Address: (Indicate Street, Apartment Number, Floor)

City: State:Zip Code:

With this signature, I certify that the information provided above is accurate.

(Include area code)

®

PA - DRS Personal AssistantChild Care Provider(Choose your Provider type)

Enter "N/A" If you do

not have a phone

Enter your name below as it appears on your Social Security Card or on your current IDHS payment checks:

Doing Business As Name: (Use this line for your DBA, if licensed with one)

(Street # and Name: with St. Ave, Ct, Apt. #, Floor)

Signature: Date:

All blanks above MUST be completed in order to request a Illinois Debit MasterCard.

I would like to CANCEL use of my Illinois Debit MasterCard and receive my payments the way I did before

requesting the Debit card (either paper check or Direct Deposit).

If you were using Direct Deposit, and that bank account is now closed, your next payment may be delayed and possibly will come in the mail. Child Care

providers must contact The Office of the Comptroller Direct Deposit Unit at (217) 557-0930 if the account has changed or closed. Personal Assistants must

contact the DRS Local Office if there have been any changes to your bank account since the last time you received Direct Deposit in order to avoid delays.

Print Your Name: Social Security Number:

Signature: Date:

COMPLETE ONLY ONE SECTION BELOW: If you want to START using the Illinois Debit MasterCard, complete section 1. If

you have a card now and wish to STOP using it, complete Section 2.

SECTION 1 (To request a new Illinois Debit MasterCard)

Reason for Card Cancellation

SECTION 2 (To cancel your Illinois Debit MasterCard)

Please retain your Illinois Debit MasterCard until you receive your next payment by check or direct deposit.

Page 44: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department
Page 45: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

FOR HEALTHCARE PROVIDERS

K N OW T H E T R U T H TO P R OT E C T YO U R S E L F A N D P R OT E C T YO U R PAT I E N T S

TRUTH: Alcohol-based hand sanitizer is more effective and less drying than using soap and water.

T H E N I T T Y G R I T T Y :Compared to soap and water, alcohol-based hand sanitizers are better at reducing bacterial counts on hands and are effective against multidrug-resistant organisms (e.g., MRSA). Additionally, alcohol-based hand sanitizers cause less skin irritation than frequent use of soap and water.

M O R EE F F E C T I V E

L E S SD RY I N G

G O O D G E R M SBA D G E R M S

TRUTH: Using alcohol-based hand sanitizer does NOT cause antibiotic resistance.

T H E N I T T Y G R I T T Y :Alcohol-based hand sanitizers kill germs quickand in a different way than antibiotics. There is no chance for the germs to adapt or developresistance.

TRUTH: Alcohol-based hand sanitizer does not kill C. difficile, but it is still the overall recommended method for hand hygiene practice.

T H E N I T T Y G R I T T Y:Always use gloves when caring for patients with C. difficile. In addition, when there is an outbreak of C. difficile in your facility, wash your hands with soap and water after removing your gloves.

TRUTH: Some healthcare providers miss certain areas when cleaning their hands.

T H E N I T T Y G R I T T Y:Using alcohol-based hand sanitizer becomes a habit and sometimes healthcare providers miss certain areas:

ly

F I N G E R T I P S

B E T W E E NF I N G E R S

T H U M B S

Page 46: T E D N U A D W U G P E I L H E O B N Q G C B A L · Form I-9 10/21/2019 Page 2 of 3 USCIS Form I-9 OMB No. 1615-0047 Expires 10/31/2022 Employment Eligibility Verification Department

Clean Hands Count 100% of the Time

P R OT E C T YO U R S E L F A N D P R OT E C T YO U R PAT I E N T S F R O M P OT E N T I A L LY D E A D LY G E R M S

TRUTH: The amount of product you use matters.

T H E N I T T Y G R I T T Y :Use enough alcohol-based hand sanitizer to cover all surfaces of your hands. Rub your hands together until they are dry. Your hands should stay wet for around 20 seconds if you used the right amount.

TRUTH: Glove use is not a substitute for cleaning your hands. Dirty gloves can soil your hands.

T H E N I T T Y G R I T T Y :Clean your hands after removing gloves to protect yourself and your patients from infection.

TRUTH: On average, healthcare providers perform hand hygiene less than half of the times they should.

T H E N I T T Y G R I T T Y :When healthcare providers do not perform hand hygiene 100% of the times they should, they put themselves and their patients at risk for serious infections.

This material was developed by CDC. The Clean Hands Count Campaign is made possible by a partnership between the CDC Foundation and GOJO.

www.cdc.gov/Hand Hygiene