City of Holyoke Personnel Department SEPTEMBER 2014 CITY OF HOLYOKE APPLICATION FOR EMPLOYMENT AS AN ELECTION WORKER DATE: ARE YOU CURRENTLY AN EMPLOYEE FOR THE CITY OF HOLYOKE, HOLYOKE GAS & ELECTRIC DEPARTMENT OR THE HOLYOKE SCHOOL DEPARTMENT? YES___NO (IF YOU ANSWER YES, PLEASE CONTACT THE CITY CLERK) POSITION APPLYING FOR: ELECTION WARDEN. ELECTION INSPECTOR, MOVER, |OVING SUPERVISOR, NAME: FIRST LAST MIDDLE INITIAL, ‘ADDRESS: STREET CITY, STATE ZIP DATE OF BIRTH: SOCIAL SECURITY NUMBEI PHONE: CELL: EMERGENCY CONTACT NAME & PHONE: certify that answers given herein are true and complete. SIGNATURE: FOR DEPARTMENT USE ONLY EMPLOYMENT DOCUMENTATION CHECKLIST Completed Application 19 SSA-1945 Voided check with Direct Deposit Agreement City Hall + 536 Dwight Street + Si Telephone: (413) 322-5555 + Facsimile: (413) 32: Birthplace of Vabeybatl 7 + Holyoke, Massachusetts 01040 356Statement Concerning Your Employment in a Job Not Covered by Social Security Employee Name Empioyee ID# Employer Name Employer ID# ‘Your earnings from this job are not covered under Social Security. When you retize, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security lav, there are two ways your Social Security benefit amount may be affected Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As aresult, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result of this provision is $313.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit, For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.” Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, Statc or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension. For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100), Even if your pension is high enough to totally offset your spouse or widow er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, " Pension Offset.” For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office. le effects of the future Social I certify that I have received Form SSA-1945 that contains information about the po: Windfall Elimination Provision and the Government Pension Offset Provision on my potenti Security benefits. Signature of Employee Form SSA-1945 (13-2004)Information about Social Security Form SSA-1945 Statement Concerning Your Employment in a Job Not Covered by Social Security New legislation (Section 419(c) of Public Law 108-203, the Social Security Protection Act of 2004] requires State and local government employers to provide a statement to employees hired January 1, 2005 or later in a job not covered under Social Security. The statement explains how a pension from that job could affect future Social Security benefits to which they may become entitled. Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is the document that employers should use to meet the requirements of the law. The SSA-1945 explains the potential effects of two provisions in the Social Security law for workers who also receive a pension based on their work in a job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker's Social Security retirement or disability benefit. The Government Pension Offset Provision can affect a Social Security benefit received as a spouse or an ex-spouse. Employers must: + Give the statement to the employee prior to the start of employment; © Get the employee's signature on the form; and ‘+ Submit a copy of the signed form to the pension paying agency. Social Security will not be setting any additional guidelines for the use of this form. Copies of the SSA-1945 are available online at the Social Security website, www.socialsecurity.eov/form1945. Paper copies can be requested by email at oplm.oswm.rqct.orcers@ssa.gov or by fax at 410-965-2037. The request must include the name, complete address and telephone number of the employer... Forms will not be sent to post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. ‘The forms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering. Form SSA-1945 (12-2004)Instructions for Employment Eligibility Verification hua ‘orm I ity (OMBNo. 1615-0087 Department of Homeland Sec Expires 0331/2016 U.S. Citizenship and Immigration Services Read all instructions earefully before completing this form. é Anti-Diserimination Notice. itis illegal to discriminate against any work authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), of 1-800-237-2515 (TDD), or visit www justice.gov/erVabout/ose. Employers must complete Form I-9 to document verification of the identity and employment authorization of cach new employee (both citizen and noncitizen) hired after November 6, 1986, 10 work in the United States. In the Commonwealth of the Northem Mariana Islands (CNMI), employers must complete Form 1-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form I-9 CNMI between November 28, 2009 and November 27, 2011 Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term “employer” means all employers, ineluding those recruiters and referrers fora fee who are agricultural associations agricultural employers, or farm labor contractors. Fonn 1-9 is made up of three sections. Employers may be fined ifthe form is not complete. Employers are responsible for retaining completed forms. Do not mail completed forms to U.S, Citizenship and Immigration Services (USCIS) or Immigration and Customs Enforce Newly hired employees must complete and sign Section | of Form I-9 no later than the first day of employment. Section 1 should never be completed before the employee has accepted a job offer. Provide the following information to complete Section 1 Name: Provide your full legal last name, first name, and middle inital. Your last name is your family name or sumame, If you have two last names or « hyphenated last name, include both names in the last name field, Your frst name is your given name. Your middle initial is the first Jeter of your second given name, or the first letter of your mniddte same, if any. Other names used: Provide all other names used, if any (including maiden name). [you have had no other iegal names, write "N/A." Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters rational address in this Geld from Canada or Mexico may use an inte example, January 23, 1950, should be Date of Birth: Prov written as 01/23/1950, U.S. Social Security Number: Provide your 9-digit Social Security number. Providi is voluntary. However, if your employer participates in E- Verify, you must provide you E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephone number, Department of Homeland Security (DHS) may contact you if DHS Ieamis of a potential mismatch beween the information provided and the information in DHS or Social Security Administration (SSA) records. You may write ‘N/A if you choose not fo provide this information de your date of birth in the mmv/dd!yyyy format. For your Social Security number etal Security aumber. EMPLOVERS MUS? REPAIN COMPLETED FORM 19 BO NOT MAM. COMPLETED FORA 9 TO ICE OR USCIS, Form 19 InstoustionsAll employees must attest in Section I, under penalty of perjury, to their citizenship or immigration status by checking ‘onc of the following four boxes provided on the form: L.A citizen of the United States 2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons bor in American ‘Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals bom abroad, 3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection, At this time, the USCIS Number is the sane as the A-Number without the "A" prefix. 4. Awalien authorized to work: Ifyou are not a citizen or national of the United States or a lawful permanent resident, but ate authorized to work in the United States, check this box. Ifyou check this box: Record the date that your employment authorization expires, if any. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Pala, may write "N/A" on this line. b, Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record ‘your Admission Number. You can find your Admission Number on Form 1-94, "Arrival-Departure Record,” or as directed by USCIS or U.S. Customs and Border Protection (CBP), @) Ifyou obtained your admission number from CBP in connection with your arrival in the United States, thea also record information about the foreign passport you used fo enter the United States (number and country of issuance), (2) Ifyou obtained your admission number from USCIS within te United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuanee fils. Sign your name in the "Signoture of Employee" block and secord the date yuu vumpleted and signed Seco 1. By signing and dating this form, you attest that the citizenship or immigration status you sclected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present (0 your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date Preparer and/or Translator Certification The Preparer and/or Translator Certification must be completed ifthe employce requires assistance to complete Section L {€.g, the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs addtional assistance), The employee must stil sign Section | Minors and Certain Employees with Disabilities (Special Placement) Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form 1-9 (M-274) on wwwausels.gov! 1.8Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18” or “special placement,” whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2 Fom 19 istrections VIB N Page 2019)Before completing Section 2, employers must ensure that Section | is completed properly and on time. Employers may not ask an individual to complete Section | before he or she has accepted a job offer Employers or their authorized representative must complete Section 2 by examining evidence of identity and employment authorization within 3 business days of the employee's first day of employment. For example, if an employee begins ‘employment on Monday, the employer must complete Section 2 by Thursday of thal week. However, if an employer hires an individual for less than 3 business days, Section 2 must be completed no later than the first day of employment, An ‘employer may complete Form I-9 before the first day of employment if the employer has offered the individual ajob and the individual has accepted Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found on the last page of Form I-9, o establish identity and employment authorization. Employees must present one selection from List A OR a combination of one selection from List B and one sclection from List C. List A contains documents that show both identity and employment authorization. Some List A documents are combination documents. The employee ‘must present combination documents together to be considered a List A document. For example, a foreign passport and a Form 1-94 contaiiing an endorsement of the alien's nonimmigrant status must be presented together to be considered a List A document. List B contains documents that show identity only, and List C contains documents that show employment authorization only. 1fan employee presents a List A document, he or she should not present a List B and List C document, and vice versa, If an employer participates in E-Verify, the List B document must inelude a photograph In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employce entered in Section I. This will help to identify the pages of the form should they get separated. Employers or their authorized representative must 1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents. Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number and 2 expitation date (ifany) from the original document(s) the employee presents. You may write "N/A" in any unused fields. If the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employer should also enter in Section 2: ‘4, The student's Form 1-20 or DS-2019 number (Student and Exchange Visitor information System-SEVIS Number); and the préyam end date from Form 1-20 or DS-2019. 3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first day the employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's fist day of employment 4, Provide the name and title of the person completing Section 2 in the Signature of Employer or Authorized Representative field attestation on the date Section 2 is completed 5. Sign and date 6. Record the employer's business name and address 7. Return the employee's docamentation. should be Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, th made for ALL new hites or reverifications. Photocopies must be retained and presented with Form 1-9 in case of aa 1n by DHS or other federal government agency. Employers must always complete Section 2 even if they ing photocopies of an employee's document(s) cannot take the place o| inspect photocopy an employee's document(s). M Form -9. Employers are still responsible for completing and retaining Form 1-9 completin Form E9 Insinctions MINVIS N Page 3089el Unexpired Documents Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present a certified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may be acceptable if the expiration date shown on the face of the document has been extended, such as for individuals with temporary protected status. Refer to the Handbook for Employers: Instructions for Completing Form 1-9 (M-274) or 1-9 Central (www.uscis,gov/l-9Central) for examples. Receipts If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in Jicu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form 1-9 for a new hire or when reverification is required Employees must present receipts within 3 business days of their first day of employment, or in the ease of reverifieation, by the date that reverification is required, and must present valid replacement documents within the time frames described below, ‘There are three types of acceptable receipts: A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The 1 ‘employee must present the actual document within 90 days from the date of hire. ‘The arrival portion of Form I-94/1-94A with a temporary I-59] stamp and a photograph of the individual, The employee must present the actual Permanent Resident Card (Form 1-551) by the expiration date of the temporary 1-551 stamp, or, if there is no expiration date, within 1 year from the date of issue. ‘The departure portion of Form I-94/1-94A with a refugee admission stamp. The employee must present an unexpired Employment Authorization Documnent (Form 1-766) or a combination of List B document and an unrestricted Social Security card within 90 days, 2 When the employee provides an acceptable receipt, the employer should 1. Record the document ttle in Section 2 under the sections titled List A, List B, or List C, as applicable 2. Write the word "receipt" and its document number in the "Document Number" field, Record the last day thatthe receipt is valid in the "Expiration Date” field By the end of the receipt validity period, the employer should: 1. Cross out the word “receipt” and any accompanying document number and expiration date 2, Record the number and other required document information from the actual document presented 3. Initial and date the change. en{ral for more See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at wewn govil- information on receipts. Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorized fo work, When rehiring an employee within 3 years of the date Form I-9 was originally completed, employers have the smpleting Section 3 in either a veverification or rehire option to complete a new Form I-9 or complete Section 3. When et situation, if the employee's name has changed, record the name change in Block A. For employees who provide an employment authorization expiration date in Section i, employers must reverify employment authorization on or before the date provided Form -9 Instructions 108/13 N Page $019A" in the space provided for the expiration date in Section | if they are aliens whose ‘Some employees may write ‘employment authorization does not expire (¢.g,, asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau), Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains 2n expiration date and requires reverification, such as Form I-766, Employment Authorization Document. Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noneitizen nationals; or 2. Lawful permanent residents who presented a Permanent Resident Card (Form I-5S1) for Section 2. Reverification docs not apply to List B documents. If both Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer should reverify by the eaclier date. For reverification, an employee must present unexpired documentation {rom either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present, To complete Section 3, employers should follow these instructions: 1. Complete Block A if an employee's name has changed at the time you complete Section 3 2. Complete Block B with the date of rehire if you rehire an employee within 3 years of the date this form was originally ‘completed, and the employee is still authorized to be employed on the same basis as previously indicated on this form. Also complete the "Signature of Employer or Authorized Representative" block. 3. Complete Block Cif: a. The employment authorization or employment authorization document of a current employee is about to expire and requires reverificatos ‘You rehire an employee within 3 years of the date this form was originally completed and his or her employment authorization or employment authorization document has expired. (Complete Block B for this employee as well.) b. To complete Block C: ‘a, Examine either a List A or List C document the employee presents that shows that the employee is currently authorized to workin the United States; and b, Record the document title, document number, and expiration date (if any) After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block, including the date. For reverification purposes, employcrs may either complete Section 3 of a new Fortn 1-9 or Section 3 of the previously completed Form 1-9. Any new pages of Form 1-9 completed during reverification must be attached to the employee's original Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containing Section 3, with the employee's name entered at the top of the page, to the employee's original Fonn 1-9. If there is a more current version of Form I-9 at the time of reverification, you must complete Section 3 of thal version of the for. SO ‘There is no fee for completing Fonn 1-9. This form isnot filed with USCIS or any government agency. Form 1-9 must be and made available for inspection by US. Goxernment officials as specified inthe "USCIS retained by the employ’ Privacy Act Statemeni below 128 should refer te the Manclbook for tion about completing Form 1-9, ensployers and employ For more detailed inforn Employers: Instructions for Completing Form 1-9 (M-274) Page 8 of 9 Fonn 19 Instructions 034813 N‘You can also obiain information about Form 1-9 from the USCIS Web site at www uscis.gov/l 9Central, by e-mailing USCIS at L9Central@dhs.gav, or by calling 1-888-464-4218, For TDD (hearing impaired), call 1-877-875-6028 To obtain USCIS forms or the Handbook for Employers, you can download them from the USCIS Web site at www.uscis, gov/fornis. You may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired), call 1-800-767-1833 Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from the USCIS Web site at wwww.dhs.gov/E- Verify, by e-mailing USCIS at E-Verify@dhs.gov or by calling 1-888-464-4218. For TDD (hearing impaired), cll 1-877-875-6028. Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling 1-888-897-7781. For TDD (hearing impaired), call 1-877-875-6028. {blank Form 19 may be reproduced, provided all sides ae copied. The instructions an Lists of Acceptable Documents ‘ust be available to all employees completing this form. Employers must retain each employee's completed Form I-9 for 2s long as the individual works for the employer. Employers are required to retain the pages of the form on which the employee and employer enter data. If copies of documentation presented by the employee are made, those copies must also be Kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 years after the date of hire or 1 year after the date employment ended, whichever i later. Form 1-9 may be signed and retained electronically, in compliance with Department of Homeland Security regulations at CER 274a.2 AUTHORITIES: The authority for collecting this information isthe Immigration Reform and Control Act of 1986, Public Law 99-603 (8 USC 1324). PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuais they hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States. DISCLOSURE: Submission of the information required in this form is voluntary. However, failure of the employer to ‘ensure proper completion of this form for each employee may result in the imposition of civil or criminal penalties. In addition, employing individuals knowing that they are unauthorized to work in the United States may subject the employer to civil andor criminal penalties ROUTINE USES: This information will be used by employers as a tecord oftheir basis for determining eligibility ofan employee to work in the United States, The employer will keep this form and make it available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel tor Immigration-Related Unfair Employment Practices, An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 35 minutes per response, including the time for reviewing instructions and completing and retaining the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Coordination Division, Office of Policy and Strategy, 20 Massachuseus Avenue NW, Washington, DC 20529-2140; OMB No 1615-0047, Do not mail your completed Form 1-9 to this address. Form 19 Intructions OMO8/13 N Page 60° 9Employment Eligibility Verification uscis Form 1-9 Department of Homeland Security (OMB.No, 1615-0047 ULS. Citizenship and Immigration Services Expies 0313172016 RE. Read instructions carafuly before completing thie form. The instructions must be avallable during competion of thls (orm. ANTLDISCRIMINATION NOTICE: itis iagal to discriminate against work. authorized individuals, Employers CANNOT specty which documents) they wil accep! from an employee. The relusal fo hie an incvdual because the documentation presented has a future expiration date msy slso constitute ilegal discrimination, J Midate iiat [Other Names Used (F297) save Je Coxe L Fiepnone Nomber ‘Address (Street Number an Name) [Apt. Number eee Date of Birth (mmidaryy) es Social Security Number ] Enal Adavess eae = iH | am aware that federal law provides for imprisonment andlor fines for false statements or use of false documents In Connection with the completion of this form, 1 attest, under penalty of perjury that | am (check one ofthe following} (1) Acttzen of tne United States C1 A roncitzen national of the United States (See instructions) 7 A towtut permanant resident (Alon Registration NumberlUSCIS Number} TZ) Anatien aunorized 1o work unl expiration date, if applicable. mmddyy) Some aliens may vite "WA" this ld (See instructions) For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Forms 1-94 Admission Number 3-0 Barcode 1. Allen Registration NumberUSCIS Number:__ tein This Space OR 2. Form I-84 Admission Number Do Not Ifyou obtained your admission number from CBP in connection with your arival inthe United Siotes, include the folowing Foreign Passport Number: _ : Country of issuance: ‘Some aliens may wile "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions) [somue tense [ome emmttinays a fattest, under penalty of perjury, that | have assisted in the completion of this form and that to the best of my knowiodge the Information is true and correct. [Senature of Preparer or Tranciotor [Date eomvtinnrs ast Name (Femiy Namo) First Name (Given Nara} (Ress (Stoat imbor ond Roma) Bayar fous se Eniployer Completes Next Page @D Form 9 03/0Employee Last Name, First Name and Midale inital from Section 1: sta oR List 8 "AND List _ldentity and Employment Authorization tsentty _Empleyment Authorization Bosiment THe ‘Document Tite: sing Author Ting Auton Bosument Number Dosamont amber Epraion ate (Fangio Expiration Dato (if ony}imm/akiyyyy Expiration Date (if amp imemidciynyy: Bocomen Te Sse AoA 3-0 Barcode Do Not Write fa This Spac [Expiration Date Wanninnmldaliayh Certification ‘attest, under penalty of perjury, that (4) I have examined the document(s) presented by the above-named employee, (2) the aboverlisted 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 Statos. The employee's first day of employment (mm/dd/yy: ___ (See instructions for exemptions.) [ate (maar ‘of Employer ot Authorized Representative {signature of Employer or Authorized Representative [casi Name Famiy ame) ‘Feet Namo (Given Name) [Employors Busneas or Organization Name [Employers Business or Orgarkzation Adaress (Steet Number and Fame} [Gy ov Town Site [ap Code 1G employee's previous grant of enployrnart auoaaion has exe prowde Ue fon fo the document Worm List Ae Uist te emetovee resorted hal etabishos cure employment authonzaton in the space proviged below JOocument Tie [Expicion Date WFanvitamiterneyy ‘attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, andit the employee presented document(s), the document(s) Ihave examined appear to be gonvine and to relate to the individual Signature of Employer or Authonzed Representative: Date immideiyyyy}’ | Pent Name of Employer or Auttonzod Reprosentatve Form 1-9 D¥08/13 Ni Page BoLISTS OF ACCEPTABLE DOCUMENTS. All documents must be UNEXPIRED Employees may present one selection from List A oF 2 combination of one selection from List B and one selection from List C. LSTA Documents that Establish Both identity and Employment Atthorization i usTB Documents that Establish Identity AND ust Documents that Establish Employment Authorization 1. U.S. Passport or US. Passport Card 2. Permanent Resident Gard or Alien Registration Rocoipt Card (Form 1-551) Foreign passport that contains a lemporary 1.551 stamp oF temporary F551 painted notation on 3 machine- readable immigrant visa : Employment Authorization Document that contains a photograph (Form +786) For a nonimmigrant alien authorized fo work for a speciic employer because of his oF her status! «2. Foreign passport: and b. Form 1:94 of Form 148 that hes the folowing: (1) The same name as the passport} and (2)An endorsement ofthe alien's nonimmigrant status as long as that period of endorsement has sot yet expired and the proposed employment is notin | ‘confit with any resinictions or | Emitations identified on the form. Passpor fiom the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI with Form 1.94 0F Forrn 194A indicating nonimmigrant admission under the ‘Compact of Free Association Between the United States and the FSM or RMI Driver's liconse or 1D card issuod by a Slate oF outiying possession of the United States provided it contains 3 photograph or informaiion such as. name, date of birth, gender, height, eye color, and address 10 card issued by federal, state or local ‘goverment agencies or entities, 4. A Sodial Security Account Number ‘card, unless the card includes one of the folowing cestictons: (1) NOT VALID FOR EMPLOYMENT (2) VALID FOR WORK ONLY WITH INS AUTHORIZATION (3) VALID FOR WORK ONLY Wirt OHS AUTHORIZATION provides It contains a photograph or Information such as name, date of bth, gender, height, eye cole, and address. 70, 4 2. For persons under age 18 who are ‘School 1D card with a photograp Voters registration card US. Miltary card or draft record ‘Miltary dependents ID cara US ‘Coast Guard Merchant Mariner Coed ‘Native American tribal document Driver's license issued by @ Canadian goverment avihority unable to present a document listed above: School record or report card Cline, doctor, or Roepial recora 2 Gerification of Bit Abroad wsued by the Department of State (Form FS-548) Caxticaton of Report of Bith 'ssuod by the Depariment of State (Form 05-1350) T Oiginal of contiod copy of tn conieat Issued by a Stat, ‘county, municipal author. ot tortor ofthe United Stas bearing an official sea | Native Amencan tribal document 8._US, Giizen ID Card (Form |-197) Identification Card for Use of Resident Citizen in the Unites ‘States (Form 1-179) 1 Employment authorization ‘document issued by the Department of Homeland Security Day-care or nursery school record lustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274), Refer to Section 2 of the instructions, titled “Employer or Authorized Representative Review and Verification," for more information about acceptable receipts. Form 9 Q3i08!13 NOFFICE OF CITY TREASURER JON D. LUMBRA CITY TREASURER SANDRA SMITH ASSISTANT TREASURER ca i Form "ereby athe City of Holyoke inte automatic depesis o my count at the ancl nsatia(s) aumed below. Lavo authori Cy of Holyoke tooakewithaval om thi acco in he event tha» ed ent e made ner. byay ures, ace noo bold City of Holyoke responsible fer any delay fos f funds det incre oncom information suppl by Financ instant an enon te pare my nani rettion in depot incr omy Aes. Forth iis understood hat ting an ting of your Ble wl determin when your mie wil be salable ough your designees account Monday holiday migh cane deposits ote made on Fay instead of Thuraday- Al if he Pay Dae isa Hold, det depois may nos be avaable atl he Father understand th the city wil prente my Fes pay an alive check wil be sued wo ensue the pope entry is made “This agreement wil ein jn effect nl City of Holyoke reeves a writen nace of caoeaion fom me my Fane insituion, oF unl brik 2 new dtet dost orm to the Payal Deparment Name of Financial Institution: Routing Number: ‘Account Number: 7 Name of Financial Institution: Routing Number: ‘Account Number: Name of Financial Institution: Checking Savings Q Routing Number Account Number ‘Checking Savings Name (Print): an Authorized Signans Date: Department Please attach a voided check{s) or deposit(s) 8 536 OWIGHT STREET - TREASURER’S OFFICE » HOLYOKE, MASSACHUSETTS 01040-5019 PHONE: (413) 322-5580 » FAX: (415) 322-5561 « EMAIL: Lumibrad@ci holyoke mous Birthplace of VolleyballPlease print or type. ror W-9 (tassacruste Substute W.9 Foo) Rev tet 2609 Request for Taxpayer Identification Number and Certification Competed form should be given to the requesting {epartment or ne department you are eurrenty doing Taine (Ua apo finan il RST are ie anes oe penton wake TN you eur Pa Sev Sle soon she 3 ‘Business name, Wailea or abow (See Specie Hsuvaton ov pape) CGneckine appropriate box: C)InciidualiSow proprietor Di corporation 1 Parnarship OF Otte Bn aga AGGTESE amber sree wndaat oramere Ramitance Adareee abcar arog Sea nv Yea ara OF ‘ity, Sate and IP code iy, Hale and BP code Phone #i Fate mat adress [EUAN Taxpayer identification Number (TIN) Enior your TIN the epotopiate box. For india. hi is your socat Secuity number (S3N}. However, for afesident allen, sole proprietor, oF ‘leregarded ontiy, 200 the Part instruction on age 2 For ofr enliies, iis your employer entation number (EI). f {out donot have a somber 8 How ta get a IN on page 2 ‘Note if tho account in more tan ona name, ae fon chart on page 2 for guideines on whose number fo enter. ‘Social security number 00-00-0000 oR Employer identification number 00-0500000 Vendors: Dunn and astoet Universal Numbering ear} Certification Undor penal of perjury, cot hat System (DUNS) uns gooon0000 1." Tha numer shown oF ths for fs my comac taxpayer etiicaon mums (or | am wal for # number tobe issued o me}, ane 2. am not subjac to backup withholding because: (a am exempt ram backup withholding (a) Ihave not been noid bythe intemal Revenue Services (IRS) that am subject fo hachup winning asa fest ota are to ropa inares or dvidends, o(e) he IRS has noted ma hat Tam no longo” subject backup winheldeg, and 3. lamanUS. person (casing an US. esident aber). 4. Lam cumenty a Corrmonweath of Massachusetts state amcloyee: (check one}: No___Yes___ yes, i compliance withthe Site Ccs CCommssion requirement, Corttieation instructions: You must crocs out ter 2 above i you have bean noted by the IRS that you are cstanty subject backup witwoksng Because you have fled rept ll interest and dividends on your lax ruin For oal esate ananetons tam ? dows na acl Sian Hore | Authorized Signature » Purpose of Form A parson voi eared fe an internation fet te eS must get yor earect Strne canteston rum IN apo, tarmsctors, mariage leet you paid. Sequin 1 debtor cortbton you made 0 sri Use Form wt only yousre a US. porson (ung oedema), ge our coat Tt he person ecuestngt ite eguescr 1. Geray ne TW you sre ang is corse (or yeu ste wating ors mumea tobe eae} 2. Comty ys are no unjectto dace sothnoing Hr you are» foreign person, use the sporopniate For 8.8. See Pub 46, ‘boing of Taxon Norceseen Aes aed Foreign Cosortons inat s ackup wihnolaing? Persons making '. You donot cea ot requeser nat yu are ot subject o bac wthindng unde adore (let reponse trent ona dderd accounts ‘pened aor 1985 593) CCensin sayees arc payments are examet on Ssclup wihhetang ‘Seeine Pan iaioetons on page 2 Penalties Faire to furnin TN. you ft fue your cores TN oa ecuesir you are subeetto 8 [enaly ef $20 french such fake uness yu va nope ‘Covi penaty for fee information with reset to mitunoldng "you mate lie sitemert snotdng. you ao bj toa $800 pony, Criminal ponaty for tying ntormation ‘Wily lle crtestons ce aematons ray supgct you to erevnal penis meluang Tes anor trgesonert eguse of TINS fire requester discos ruses Tie aan of Focal. equosto ay Feim WA-W-S (Rev Apr 2008)Specific Instructions Nome, I you ato anal, you must ‘geval erie ne name shown on you seca Senuniy card. However, il younave changed Sourlatiname, for nance, da to marge ‘wthost fring te Socal Secu TReminaton of te mare daange enter your fet nam the fst nae shown on yur sola Seoul ona your new nt name ite accounts inant names ts fs! ace then rela fe name ofthe sen a entty ‘hose nanber you oer in Pat oft em. ‘Sole propeietor. Ener your indviual name {2 snoun on your sot sec carn he Nome’ ne Yau may enor your business, ‘ade ot doin bvoaess as (084) rare on ‘ne Busines name’ ne, Limits tabity company (LLC) you area ‘Singemerb= LLC nti a fren LLC ‘rei somoste owe tet ie eregared sx {Sr euly soparate forts oweor net ‘rosary regular secton 901 77013 enter {he owners name onthe “Name” tno, Ene the Lies name on be "Bushess nme" Ine Caution: A etegantce domestic ant at bor eraign ownor ust uso te appropiate Fon 8 Other ents. Ener your tusnest name 36 ‘Shown on ered Fed tox decumants on rata anoun 9 he shares o ier cg ‘eserert erst ne ety You may niet business. re, o DBA nama on [ETI - Taxpayer entitication Number (TIN) Enter your TIN in the appropriate box. you te a rion allen ad you do 1 Neve and ore ot ets toga an SSN, your Tvs your RS weal oxpayer ‘Benwfestin number (TIN) Ete in the {oe secury number box you da rot have STI, soa How ta get a TN bow Iryou ae 2 sole propistor ara you nave an EN youroy ener thar your SON or EN However ie RS peers thal you use your ssi you are an LLC tts dlsregarded 3s an tntty sparte eam ts ouner (0 Lod Til company (UC) above), and are ‘ered by an india snier your SEN or roti Bit fdesred) Ihe gone: ofa ges LC a eperaon pares, fe. etorthe oomars ER, Note See the car on tis page or utnor Dneaton of eme ond TA eambinaions How to get a TIN. tfyeu do rathave 9 {IN 260 or one mesial To apoyo 3m SSH, get Form 88-5, Aotoaton or Sora! ‘Secu Card fom you lal Scat Sec, ‘Ramanvation fen Gel Porm Wer, Repeston for IRS Indes! Texpayer sertfeaton Numb, {o.apey fran ITN of Fors 98-4, appicatin for [Emesope loonefeaten Nubar. 0 2pey fan EN You can got Forme 17 ana SS. For the TRS by cling $-800-TAK FORM (-000-025 [Je] or fom he IRS's eet Web Sie wo .08 {you donot nave 2 TN, wit “Ape For in the spans forthe TIN, i and date ar, 300 (Gato tre requester Forres ne dans evens 6 cris payments made nih eapect frend tradable nevumart, generaly {our hav 60 days o ge'a MM and ave to the requedier bate you se subjet stash ‘wénnaling on payments “To Gon ule does at apy to ober types of Payments You wi be sujet oh (tinal ona sues payrecte wah you rows your MN othe Feguoster Note. Wing “Asoc For means set you nove ‘tends apobed tore TIN or that you fons © ‘pny rama soon (EGAIE - Certification To establish o me paying agort tha your TNs EyccloryouareeuS paren ovrossert fen sign Form Ww, For joint aacuct, cry he person wit TN ie ‘hommin Pat shoud sgn fen ead) eal estate rensactons. You mut sign tha tarieaton, ou may cess out Fem 2 of De certeaton ‘unm and Brndstrest Universal Numbering Syren (DUNG) number eaorement— ‘Fos untad Sate Gos Wansgonen’ and Sudoet {ones hars et DON be ores wih a ‘nbreouoly epoted wine garg epee. We Seneacor hs tine GUNS monte the ‘Siiactr shows pre te prnayrber ted eine Poona govormnants Carr Consacon Feaiaton (CCR) at fencer ang Ary ony tt [Efernthowes QUNG rumber2an apy one on Privacy Act Notice ‘Section 6109 ofthe nena! Revenue Code fecques yuo ge four correct TN io persons (tho nut le ernaon return wth fo 20 ‘ooo wrest cen. ond cova chor ‘come pd 1 you. otgage rarest you the soqumiton ar abancaneert a scares Fraps, esnealision of deb, o sartaubens SrrmadetoanIRa or MGA. The IRS use the Fores for deniteaton purpones and a helo ‘rye aceiany of your trout The eS Inay also powee ts wlrration othe ‘Deparment of Jose ore ana cman ligeten, ana ctes, stale, sna Dit of {Calin tocar out tect awe ‘You mest provte your TIN whether or nl you sre ered fof atx eka, Payers must ‘Seneatywithol a deste paaniage, Serenly 29% of taabie mere dkadona nd Coron se payment toa payee wo doce ot Qvea TN iow poyar Cora penshes may also Soy Faris yee of eccout | — Farm ype craecoune | What Name and Number to Give the Requester [ Give name sna WoT 1 rewniat The ial 2 Twoormoe ‘he sce owner ofthe iraraduas jot | Secount combos emu) funds, fst ‘en he 2, Caste account of | Tre menor ® nin (Usiom a foliar: Ae) 4 goo usual revoeabi avis tron enone seo ste) bs Soeated ust 3 ogat orate trot under slate 5. Sole ropnetrenip ‘The grntoctusice! Te seus ner Te cane Sate ropieiorhip | Te owner? 7 Avalon esate or | Lagat eaity* pension Sampo {he corortion 5) Asemaaton cus, | The orarveation religous chara, (ucatons oes ‘Breaxomatogemeaton 10, Pema ‘Poe games TH. Biwoker aegistared | Tho ok or ominn 42, Remouniwihihe | The pbc enty ‘Separnantet Daerah rome (ta be ety ouch Sean recs government shoo! ‘ett or pison) that receines ogc progear payments number you umnsn. lf eny one pean on 2 Jont ‘eeoun! basen SON, tat pera momoee ms bo fre ® Cc the mino's nee an arian the minors SN. + You must show yor ined name, out you may ‘aso-mtar your business or DBR nore, You ay ‘ee eee your SN oF EIN you have on). “Li fet ans ete re namo ote egal wus esate, ‘rgension ust {09 not mh te TIN one povsoolepresetaive or wtos unless ne legal nus foots net desgetedn he socou ie) Note: no nme is ssed whan mare than one name ‘Silsie, Ihe nuter mi be consiered tobe that of the testnare sted 1 you have questions on completing this form, [lense contet the Otice a the State Compal (err) 973.2008. Upon completion of this form, please ‘send it to the Commonwealth of Massachusetts Department you are doing business with. Page 2 Fim MA-W9 (Rev, Apt 2008),