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Company Code:
(1) T he Electronic completion and submission process whereby after a few simple steps, you can forward an email
to the new hire to complete the registration process in My TotalSource online independently,
or
(2) T he Paper-based process whereby you can register the employee in My TotalSource online after they fill out
their new-hire paperwork by hand.1
PRACTICE TIP: Federal law requires employees to fill out Section 1 of the Form I-9 no later than the first day of
employment. Therefore, if you are using the electronic completion and submission process, you must register your new
employee as soon as possible to allow the employee to complete Section 1 on time. This will also allow you to meet
the legal obligations of an employer to complete Section 2 within three business days of the first day of employment.
Employers using the paper-based process must ensure they meet the same requirements, only this will be accomplished
by completing a paper Form I-9.
For employers in states that require E-Verify, it is critical that your Form I-9 information be input into My TotalSource within
three business days of the first day of employment so your employee can be verified.
1
New-hire registration forms can also be faxed in to your Payroll Service Representative in the event you cannot access My TotalSource.
2
Option 1: The Electronic Completion and Submission Process
/ / /
EMPLOYER
1 Complete
Employment
2 Register New
Hire(by the 1st day
3 Complete employer
portion of Form I-9
Profile in of employment) (by the 3rd day)
My TotalSource
HIRED
/ / /
EMPLOYEE
1 Register with
My TotalSource
2 Watch
welcome
3 Complete new-hire
paperwork online
(Form I-9: Section 1
online video must be returned by
the 1st day)
If you would like to switch to the electronic completion and submission process, please contact your Payroll Service Representative.
If you elect to perform a background investigation, the Background Check Input screen lets you enter the information
required for ADP TotalSource to conduct a background investigation on your new employee.
Please provide the new hire with a Background Check Disclosure and Authorization Form.
- A copy of the form can be found in this booklet as well as the Pre-Employment section of FormSource on
My TotalSource.
- Note: W
hen you check the box next to each type of background check you want to order, it will let you know what
information you need to ask the employee to supply.
Employee Instructions pages from New Hire Booklet and the forms contained therein (including the I-9 Employment
Eligibility Verification Form)
Basic Employment Policies or Welcome Statement for union employees (specific state versions are available for CA, CT,
HI, MA, ME, MT, NJ, RI, SC, TN, VT and are located in the State Appendix section of FormSource)
State withholding form for employees worked-in state (if applicable)
Certain states require specific forms be given to new hires
- Please consult the State Appendix section of FormSource to see if your state has such requirements.
3
Collect the following forms from the new employee: (check for completeness and signatures)
Complete the Employment Profile and Personal Profile in ADP TotalSources online system, My TotalSource
(www.mytotalsource.com).
Complete and sign Section 2 of the I-9 Employment Eligibility Verification form and verify employee documents and
signature. (Federal law requires you complete the Form I-9 within three business days of the employees first day of
employment. If you are in a state that requires that you use E-Verify, you must query E-Verify within three business
days of employment as well. ADP TotalSource will initiate the E-Verify query on your behalf as soon as you submit
the Form I-9 information to us.)
lease refer to FormSource for detailed instructions on the Form I-9. The E-Verify User Guide can be found on the
P
E-Verify Dashboard.
Enter the rest of the new employee information on My TotalSource, including the new hires Form I-9 information.
After you are finished entering the new employees information on My TotalSource, a link for a Welcome Kit will appear
under Next Steps/Status. You can print out the Welcome Kit to give to the new employee, or save a copy and email it to your
new employee. The Welcome Kit includes instructions for your new employee to log in to My TotalSource.
Please give each new hire a copy of the applicable Basic Employment Policies (or Welcome Statement for union employees)
with the Welcome Kit.
You can find a copy of the Basic Employment Policies and Welcome Statement in the New Hire section of FormSource, or
in the State Appendix for states with specific Basic Employment Policies (CA, CT, HI, MA, ME, MT, NJ, RI, SC, TN, VT).
Fax a copy of the completed and signed Basic Employment Policies Acknowledgment or Welcome Statement
Acknowledgment form to your Payroll Service Representative within three business days after selecting the individual
for hire.
Note: Record Retention: A copy of the Form I-9 must be maintained by your company for three years after the employee
terminates employment or one year after the date of hire, whichever is later.
4
EMPLOYER USE ONLY
(PLEASE PRINT CLEARLY)
Social Security No.: Original Hire Date: TotalSource Start Date: File Number: Background Check:
(If different) (If not auto-assigned),
Yes No
_____________________________________ ______________________ __________________________ ____________________ (If YES, include a Consent
to Conduct Background
Investigation Form)
Pay Frequency: weekly bi-weekly (26 pay periods/yr.) semi-monthly (24 pay periods/yr) monthly
________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
5
FS104
Employee Instructions:
ADP TotalSource provides you with two ways to register in our system:
(1) T he Electronic completion and submission process whereby you complete the registration process in
My TotalSource online independently,
or
(2) The Paper-based process whereby you complete and sign the forms in this booklet by hand and return
them to your Worksite Employer.
Your employer will let you know which process you will be using.
Complete the following forms, including your signature where indicated and return them to your Worksite Employer:
Section 1 of the I-9 Employment Eligibility Verification Form - must be completed no later than your first day
of employment
Background Check Disclosure and Authorization Form (if required by your Worksite Employer)
In addition to the list above, your Worksite Employer will provide you with a copy of the Basic Employment Policies or a
Welcome Statement if you are a union employee.
You may also need to fill out a State Withholding Certificate (if required by your state).
Please sign the last page of the Basic Employment Policies or the first page of the Welcome Statement and return it
to your Worksite Employer with the State Withholding Certificate (if applicable).
After you are set up in the ADP TotalSource system, you will receive a Welcome Kit with information about how to access
My TotalSource.
Once you log in to My TotalSource, be sure to access the online version of the Employee Welcome Kit where youll find more
details on all the great advantages you have access to now that your company is partnering with ADP TotalSource!
6
EMPLOYEE PERSONAL INFORMATION
(PLEASE PRINT CLEARLY)
Name of Worksite Employer:
F R Aleman Associates
________________________________________________________________________________________________________
657-32-5536
Social Security Number:_______________________________ __________
07 October, 1983
Birth Date: ____________________________________________________
Contact Information
Are you subject to any city or local income taxes? Yes No
Home Address
2549 Grassy Point Dr.
Street 1: ______________________________________________________
If so, please provide the city and/or locales below:
Florida 32746
State:____________________ Zip: ________________________________
_________________________ _________________________
omor.sharif@fr-aleman.com
Business Emai: ________________________________________________ Maiden Name ________________________________________________
407-804-9100
Work Phone: __________________________________________________ Ethnic Group: Are you Hispanic or Latino? Yes x No
803-319-0437
Cell Phone: ____________________________________________________
If not Hispanic or Latino, please indicate below:
White Black or African American
Work-in State:__________________________________________________
x Asian American Indian/Alaska Native
Two or more races Native Hawaiian or other Pacific Islander
Asif Anwar
Name: ________________________________________________________
Rassel Raihan
Name: ________________________________________________________
803-414-8686
Cell Phone: ____________________________________________________ 307-460-1197
Cell Phone: ____________________________________________________
Friend/Colleague
Relationship: __________________________________________________
Friend/Colleague
Relationship: __________________________________________________
____________________________________________________________________________________________________________________________________
7
FS104
Form W-4 (2013) Complete all worksheets that apply. However, you
may claim fewer (or zero) allowances. For regular
wages, withholding must be based on allowances
income, see Pub. 505 to find out if you should adjust
your withholding on Form W-4 or W-4P.
Two earners or multiple jobs. If you have a
Purpose. Complete Form W-4 so that your you claimed and may not be a flat amount or working spouse or more than one job, figure the
employer can withhold the correct federal income percentage of wages. total number of allowances you are entitled to claim
tax from your pay. Consider completing a new Form Head of household. Generally, you can claim head on all jobs using worksheets from only one Form
W-4 each year and when your personal or financial of household filing status on your tax return only if W-4. Your withholding usually will be most accurate
situation changes. you are unmarried and pay more than 50% of the when all allowances are claimed on the Form W-4
Exemption from withholding. If you are exempt, costs of keeping up a home for yourself and your for the highest paying job and zero allowances are
complete only lines 1, 2, 3, 4, and 7 and sign the dependent(s) or other qualifying individuals. See claimed on the others. See Pub. 505 for details.
form to validate it. Your exemption for 2013 expires Pub. 501, Exemptions, Standard Deduction, and Nonresident alien. If you are a nonresident alien,
February 17, 2014. See Pub. 505, Tax Withholding Filing Information, for information. see Notice 1392, Supplemental Form W-4
and Estimated Tax. Tax credits. You can take projected tax credits into Instructions for Nonresident Aliens, before
Note. If another person can claim you as a account in figuring your allowable number of completing this form.
dependent on his or her tax return, you cannot claim withholding allowances. Credits for child or Check your withholding. After your Form W-4 takes
exemption from withholding if your income exceeds dependent care expenses and the child tax credit effect, use Pub. 505 to see how the amount you are
$1,000 and includes more than $350 of unearned may be claimed using the Personal Allowances having withheld compares to your projected total tax
income (for example, interest and dividends). Worksheet below. See Pub. 505 for information on for 2013. See Pub. 505, especially if your earnings
converting your other credits into withholding exceed $130,000 (Single) or $180,000 (Married).
Basic instructions. If you are not exempt, complete allowances.
the Personal Allowances Worksheet below. The Future developments. Information about any future
worksheets on page 2 further adjust your Nonwage income. If you have a large amount of developments affecting Form W-4 (such as
withholding allowances based on itemized nonwage income, such as interest or dividends, legislation enacted after we release it) will be posted
deductions, certain credits, adjustments to income, consider making estimated tax payments using Form at www.irs.gov/w4.
or two-earners/multiple jobs situations. 1040-ES, Estimated Tax for Individuals. Otherwise, you
may owe additional tax. If you have pension or annuity
C Enter 1 for your spouse. But, you may choose to enter -0- if you are married and have either a working spouse or more
than one job. (Entering -0- may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D
E Enter 1 if you will file as head of household on your tax return (see conditions under Head of household above) . . E
F Enter 1 if you have at least $1,900 of child or dependent care expenses for which you plan to claim a credit . . . F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
If your total income will be less than $65,000 ($95,000 if married), enter 2 for each eligible child; then less 1 if you
have three to six eligible children or less 2 if you have seven or more eligible children.
If your total income will be between $65,000 and $84,000 ($95,000 and $119,000 if married), enter 1 for each eligible child . . . G
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) a H 2
{
If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
For accuracy, and Adjustments Worksheet on page 2.
complete all If you are single and have more than one job or are married and you and your spouse both work and the combined
worksheets earnings from all jobs exceed $40,000 ($10,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to
that apply. avoid having too little tax withheld.
If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.
Separate here and give Form W-4 to your employer. Keep the top part for your records.
Form W-4
Department of the Treasury
Employee's Withholding Allowance Certificate
a Whether you are entitled to claim a certain number of allowances or exemption from withholding is
OMB No. 1545-0074
2013
Internal Revenue Service subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
1 Your first name and middle initial Last name 2 Your social security number
ABUL BASHAR M. OMOR SHARIF 657-32-5536
Home address (number and street or rural route)
3 Single Married Married, but withhold at higher Single rate.
2549 GRASSY POINT DR., UNIT 109 Note. If married, but legally separated, or spouse is a nonresident alien, check the Single box.
City or town, state, and ZIP code
4 If your last name differs from that shown on your social security card,
LAKE MARY, FL 32746 check here. You must call 1-800-772-1213 for a replacement card. a
5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5
6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $
7 I claim exemption from withholding for 2013, and I certify that I meet both of the following conditions for exemption.
Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and
This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write Exempt here . . . . . . . . . . . . . . . a 7
Under penalties of perjury, I declare that I have examined this certificate and, to the best of my knowledge and belief, it is true, correct, and complete.
Employees signature
(This form is not valid unless you sign it.) a Date a
8 Employers name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2013)
8
Form W-4 (2013) Page 2
Deductions and Adjustments Worksheet
Note. Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.
1 Enter an estimate of your 2013 itemized deductions. These include qualifying home mortgage interest,
charitable contributions, state and local taxes, medical expenses in excess of 7.5% of your income, and
miscellaneous deductions . . . . . . . . . . . . . . . . . . . . . . . . . 1 $
Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)
Note. Use this worksheet only if the instructions under line H on page 1 direct you here.
1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1
2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if
you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter more
than 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter
-0-) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . 3
Note. If line 1 is less than line 2, enter -0- on Form W-4, line 5, page 1. Complete lines 4 through 9 below to
figure the additional withholding amount necessary to avoid a year-end tax bill.
4 Enter the number from line 2 of this worksheet . . . . . . . . . . 4
5 Enter the number from line 1 of this worksheet . . . . . . . . . . 5
6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . 6
7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . 7 $
8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . 8 $
9 Divide line 8 by the number of pay periods remaining in 2013. For example, divide by 25 if you are paid every two
weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2013. Enter
the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck 9 $
Table 1 Table 2
Married Filing Jointly All Others Married Filing Jointly All Others
If wages from LOWEST Enter on If wages from LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter on
paying job are line 2 above paying job are line 2 above paying job are line 7 above paying job are line 7 above
$0 - $5,000 0 $0 - $8,000 0 $0 - $72,000 $590 $0 - $37,000 $590
5,001 - 13,000 1 8,001 - 16,000 1 72,001 - 130,000 980 37,001 - 80,000 980
13,001 - 24,000 2 16,001 - 25,000 2 130,001 - 200,000 1,090 80,001 - 175,000 1,090
24,001 - 26,000 3 25,001 - 30,000 3 200,001 - 345,000 1,290 175,001 - 385,000 1,290
26,001 - 30,000 4 30,001 - 40,000 4 345,001 - 385,000 1,370 385,001 and over 1,540
30,001 - 42,000 5 40,001 - 50,000 5 385,001 and over 1,540
42,001 - 48,000 6 50,001 - 70,000 6
48,001 - 55,000 7 70,001 - 80,000 7
55,001 - 65,000 8 80,001 - 95,000 8
65,001 - 75,000 9 95,001 - 120,000 9
75,001 - 85,000 10 120,001 and over 10
85,001 - 97,000 11
97,001 - 110,000 12
110,001 - 120,000 13
120,001 - 135,000 14
135,001 and over 15
Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this You are not required to provide the information requested on a form that is subject to the
form to carry out the Internal Revenue laws of the United States. Internal Revenue Code Paperwork Reduction Act unless the form displays a valid OMB control number. Books or
sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your records relating to a form or its instructions must be retained as long as their contents may
employer uses it to determine your federal income tax withholding. Failure to provide a become material in the administration of any Internal Revenue law. Generally, tax returns and
properly completed form will result in your being treated as a single person who claims no return information are confidential, as required by Code section 6103.
withholding allowances; providing fraudulent information may subject you to penalties. Routine The average time and expenses required to complete and file this form will vary depending
uses of this information include giving it to the Department of Justice for civil and criminal on individual circumstances. For estimated averages, see the instructions for your income tax
litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions return.
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 If you have suggestions for making this form simpler, we would be happy to hear from you.
countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal See the instructions for your income tax return.
laws, or to federal law enforcement and intelligence agencies to combat terrorism.
9
Instructions for Employment Eligibility Verification USCIS
Form I-9
Department of Homeland Security OMB No. 1615-0047
U.S. Citizenship and Immigration Services Expires 03/31/2016
General Instructions
Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term
"employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations,
agricultural employers, or farm labor contractors.
Form I-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible for
retaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) or
Immigration and Customs Enforcement (ICE).
10
All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checking
one of the following four boxes provided on the form:
1. A citizen of the United States
2. A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in American
Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen
nationals born abroad.
3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides
in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term
"lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration
Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the
same as the A-Number without the "A" prefix.
4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident,
but are authorized to work in the United States, check this box.
If you check this box:
a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization does
not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the
Marshall Islands, or Palau, may write "N/A" on this line.
b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the
same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record
your Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or as
directed by USCIS or U.S. Customs and Border Protection (CBP).
(1) If you obtained your admission number from CBP in connection with your arrival in the United States, then
also record information about the foreign passport you used to enter the United States (number and country of
issuance).
(2) If you obtained your admission number from USCIS within the United States, or you entered the United States
without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance
fields.
Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing
and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware
that you may be imprisoned and/or fined for making false statements or using false documentation when completing this
form. To fully complete this form, you must present to your employer documentation that establishes your identity and
employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the
last page of this form. You must present this documentation no later than the third day after beginning employment,
although you may present the required documentation before this date.
Receipts
If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in
lieu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a person
has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not
acceptable. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when
completing Form I-9 for a new hire or when reverification is required.
Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification,
by the date that reverification is required, and must present valid replacement documents within the time frames described
below.
There are three types of acceptable receipts:
1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. The
employee must present the actual document within 90 days from the date of hire.
2. The arrival portion of Form I-94/I-94A with a temporary I-551 stamp and a photograph of the individual. The
employee must present the actual Permanent Resident Card (Form I-551) by the expiration date of the temporary
I-551 stamp, or, if there is no expiration date, within 1 year from the date of issue.
3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an unexpired
Employment Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social
Security card within 90 days.
See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at www.uscis.gov/I-9Central for more
information on receipts.
START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which
document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future
expiration date may also constitute illegal discrimination.
Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later
than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name) Middle Initial Other Names Used (if any)
Address (Street Number and Name) Apt. Number City or Town State Zip Code
Date of Birth (mm/dd/yyyy) U.S. Social Security Number E-mail Address Telephone Number
- -
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):
A citizen of the United States
A noncitizen national of the United States (See instructions)
A lawful permanent resident (Alien Registration Number/USCIS Number):
An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy) . Some aliens may write "N/A" in this field.
(See instructions)
For aliens authorized to work, provide your Alien Registration Number/USCIS Number OR Form I-94 Admission Number:
1. Alien Registration Number/USCIS Number:
3-D Barcode
OR Do Not Write in This Space
2. Form I-94 Admission Number:
If you obtained your admission number from CBP in connection with your arrival in the United
States, include the following:
Country of Issuance:
Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)
Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the
employee.)
I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the
information is true and correct.
Address (Street Number and Name) City or Town State Zip Code
Employee Last Name, First Name and Middle Initial from Section 1:
Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy): Expiration Date (if any)(mm/dd/yyyy):
Document Title:
Issuing Authority:
Document Number:
Issuing Authority:
Document Number:
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.)
Signature of Employer or Authorized Representative Date (mm/dd/yyyy) Title of Employer or Authorized Representative
Last Name (Family Name) First Name (Given Name) 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) (mm/dd/yyyy):
C. If employee's previous grant of employment authorization has expired, provide the information for the document from List A or List C the employee
presented that establishes current employment authorization in the space provided below.
Document Title: Document Number: Expiration Date (if any)(mm/dd/yyyy):
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: Date (mm/dd/yyyy): Print Name of Employer or Authorized Representative:
1. U.S. Passport or U.S. Passport Card 1. Driver's license or ID card issued by a 1. A Social Security Account Number
State or outlying possession of the card, unless the card includes one of
2. Permanent Resident Card or Alien
United States provided it contains a the following restrictions:
Registration Receipt Card (Form I-551)
photograph or information such as (1) NOT VALID FOR EMPLOYMENT
name, date of birth, gender, height, eye
3. Foreign passport that contains a color, and address (2) VALID FOR WORK ONLY WITH
temporary I-551 stamp or temporary INS AUTHORIZATION
I-551 printed notation on a machine- 2. ID card issued by federal, state or local (3) VALID FOR WORK ONLY WITH
readable immigrant visa government agencies or entities, DHS AUTHORIZATION
provided it contains a photograph or
4. Employment Authorization Document information such as name, date of birth, 2. Certification of Birth Abroad issued
that contains a photograph (Form gender, height, eye color, and address by the Department of State (Form
I-766) FS-545)
3. School ID card with a photograph
5. For a nonimmigrant alien authorized 3. Certification of Report of Birth
to work for a specific employer 4. Voter's registration card issued by the Department of State
because of his or her status: (Form DS-1350)
5. U.S. Military card or draft record
a. Foreign passport; and 4. Original or certified copy of birth
6. Military dependent's ID card certificate issued by a State,
b. Form I-94 or Form I-94A that has
county, municipal authority, or
the following: 7. U.S. Coast Guard Merchant Mariner territory of the United States
(1) The same name as the passport; Card bearing an official seal
and
8. Native American tribal document 5. Native American tribal document
(2) An endorsement of the alien's
nonimmigrant status as long as 9. Driver's license issued by a Canadian
6. U.S. Citizen ID Card (Form I-197)
that period of endorsement has government authority
not yet expired and the 7. Identification Card for Use of
proposed employment is not in For persons under age 18 who are Resident Citizen in the United
conflict with any restrictions or unable to present a document States (Form I-179)
limitations identified on the form. listed above:
8. Employment authorization
6. Passport from the Federated States of document issued by the
10. School record or report card
Micronesia (FSM) or the Republic of Department of Homeland Security
the Marshall Islands (RMI) with Form 11. Clinic, doctor, or hospital record
I-94 or Form I-94A indicating
nonimmigrant admission under the 12. Day-care or nursery school record
Compact of Free Association Between
the United States and the FSM or RMI
Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274).
I choose to waive Direct Deposit Authorization (Otherwise complete Direct Deposit Authorization information below)
Employees are allowed to set up a maximum of five direct deposit accounts. A maximum of three checking accounts
and two saving accounts are allowed.
Account Number:
Your bank account number follows the transit
number on the lower, left corner of the check.
Transit Number:
A nine-digit number located in the lower, left
corner of the check.
Account Type Transit/ABA Number Account Number Full Net Deposit Partial Deposit Amount
(Check if partial deposit)
Authorization Statement
By signing the Direct Deposit Authorization form below you are agreeing to the following:
- I authorize ADP TotalSource and the bank listed above to deposit my net pay or a portion thereof as indicated into my
account each pay date.
- If funds to which I am not entitled are deposited to my account, I authorize ADP TotalSource to direct the bank to return
said funds to ADP TotalSource.
- I understand that my deposit may not be credited to my account until midnight on the pay date indicated on the check
voucher.
- I understand that it is my responsibility to ensure that my wages are being deposited correctly into my account each pay date.
- I understand that each new account will go through a pre-notification process that may take two payroll periods to complete.
P2-106-1108
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BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM
In the interest of maintaining the safety and security of our customers, employees and property, ADP TotalSource and my Worksite
Employer (collectively the Company) will order a consumer report (a background report) on you in connection with your employment
application, and if you are hired, or if you already work for the Company, may order additional background reports on you for employment
purposes.
The background check company, ADP Screening and Selection Services, will prepare the background report for the Company. ADP
Screening and Selection Services is located at 301 Remington Street, Fort Collins, CO, 80524, and can be reached at 800-367-5933.
The background report may contain information concerning your character, general reputation, personal characteristics, mode of living,
and credit standing. The types of information that may be ordered include but are not limited to: Social Security number verification;
criminal, public, educational and, as appropriate, driving records checks; verification of prior employment; reference, licensing and
certification checks; credit reports; and drug testing results. The information may be obtained from private and public record sources,
including personal interviews with your associates, friends, and neighbors. (An investigative consumer report is a background report
that includes information from such personal interviews, except in California where that term means any background report.) The nature
and scope of the most common form of investigative consumer report is an investigation into your education and/or employment history
conducted by ADP Screening and Selection Services or another outside organization.
You may request more information about the nature and scope of an investigative consumer report, if any, by telephoning the Company.
A summary of your rights under the Fair Credit Reporting Act is also being provided to you with this form.
If you live or work for the Company in the states listed below, please note the following:
CALIFORNIA: You may view the file that ADP Screening and Selection Services has for you, and order a copy of the file, upon
submitting proper identification and paying copying costs, by coming to their offices, during normal business hours and on reasonable
notice, or by mail. You may also ask for a file-summary by telephone. ADP Screening and Selection Services can answer questions
about information in your file, including any coded information. If you come in person, another person can come with you, so long as that
person can show proper identification.
MAINE: If you ask us, you have the right to know whether the Company ordered an investigative consumer report on you. You may
request the name, address, and telephone number of the nearest office for ADP Screening and Selection Services. You will get this
information within 5 business days of our receipt of your request. You have the right to ask ADP Screening and Selection Services for a
free copy of the report.
MARYLAND: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an
unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
MASSACHUSETTS/NEW JERSEY: If you submit a request to us in writing, you have the right to know whether the Company ordered an
investigative consumer report from ADP Screening and Selection Services. You may inspect and order a free copy of the report by
contacting ADP Screening and Selection Services.
MINNESOTA: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate disclosure of
the nature and scope of the consumer report or investigative consumer report ordered, if any.
NEW YORK: If you submit a request to us in writing, you have the right to know whether the Company ordered a consumer report or an
investigative consumer report from ADP Screening and Selection Services, and you will be provided with the name and address of ADP
Screening and Selection Services. You may inspect and order a free copy of the reports by contacting ADP Screening and Selection
Services. A copy of Article 23A of the New York Correction Law is being provided with this form.
OREGON: If the Company obtains credit history information on you, it will be used to evaluate whether you would present an
unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
WASHINGTON STATE: If you submit a request to us in writing, you have the right to get from the Company a complete and accurate
disclosure of the nature and scope of the investigative consumer report we ordered, if any. You also have the right to ask AD P Screening
and Selection Services for a written summary of your rights under the Washington Fair Credit Reporting Act. If the Company obtains
information bearing on your credit worthiness, credit standing or credit capacity, it will be used to evaluate whether you would present an
unacceptable risk of theft or other dishonest behavior in the job for which you are being considered.
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AUTHORIZATION FOR BACKGROUND CHECKS
After carefully reading this Background Check Disclosure and Authorization form, I authorize ADP TotalSource and my
Worksite Employer (collectively the Company) to order my background report, including investigative consumer reports. I
understand that the Company may rely on this authorization to order additional background reports, including investigative
consumer reports, during my employment without asking me for my authorization again as allowed by law.
I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all
information about or concerning me, including but not limited to: my past or present employers; learning institutions,
including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local
courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector
repositories of information; and any other person, organization, or agency with any information about or concerning me.
The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited
to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal
history, military service, professional credentials and licenses and substance abuse testing.
I agree the Company may rely on this authorization to order background reports, including investigative consumer reports,
from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed
by law. I also agree that a copy of this form is valid like the signed original. I certify that all of my personal information on
this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with the
Company, or if I am hired or already work for the Company, that my employment may be terminated.
Addresses Within The Past Seven Years (use a separate sheet as needed)
City/State/ZIP _______________________________________________________________________________________
City/State/ZIP _______________________________________________________________________________________
______________________________________________________________ _____/_______/________
Signature Date: (Month/Day/Year)
If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy
of your background check report:
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NEW YORK CORRECTION LAW
ARTICLE 23-A
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES
Section 750. Definitions.
751. Applicability.
752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited.
753. Factors to be considered concerning a previous criminal conviction; presumption.
754. Written statement upon denial of license or employment.
755. Enforcement.
750. Definitions. For the purposes of this article, the following terms shall have the following meanings:
(1) "Public agency" means the state or any local subdivision thereof, or any state or local department, agency, board or commission.
(2) "Private employer" means any person, company, corporation, labor organization or association which employs ten or more
persons.
(3) "Direct relationship" means that the nature of criminal conduct for which the person was convicted has a direct bearing on his
fitness or ability to perform one or more of the duties or responsibilities necessarily related to the license, opportunity, or job in
question.
(4) "License" means any certificate, license, permit or grant of permission required by the laws of this state, its political subdivisions
or instrumentalities as a condition for the lawful practice of any occupation, employment, trade, vocation, business, or profession.
Provided, however, that "license" shall not, for the purposes of this article, include any license or permit to own, possess, carry, or fire
any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5) "Employment" means any occupation, vocation or employment, or any form of vocational or educational training. Provided,
however, that "employment" shall not, for the purposes of this article, include membership in any law enforcement agency.
751. Applicability. The provisions of this article shall apply to any application by any person for a license or employment at any public or
private employer, who has previously been convicted of one or more criminal offenses in this state or in any other jurisdiction, and to any
license or employment held by any person whose conviction of one or more criminal offenses in this state or in any other jurisdiction preceded
such employment or granting of a license, except where a mandatory forfeiture, disability or bar to employment is imposed by law, and has not
been removed by an executive pardon, certificate of relief from disabilities or certificate of good conduct. Nothing in this article shall be
construed to affect any right an employer may have with respect to an intentional misrepresentation in connection with an application for
employment made by a prospective employee or previously made by a current employee.
752. Unfair discrimination against persons previously convicted of one or more criminal offenses prohibited. No application for any
license or employment, and no employment or license held by an individual, to which the provisions of this article are applicable, shall be
denied or acted upon adversely by reason of the individual's having been previously convicted of one or more criminal offenses, or by reason
of a finding of lack of "good moral character" when such finding is based upon the fact that the individual has previously been convicted of one
or more criminal offenses, unless:
(1) There is a direct relationship between one or more of the previous criminal offenses and the specific license or employment
sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment would involve an unreasonable risk
to property or to the safety or welfare of specific individuals or the general public.
753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall
consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and employment of persons
previously convicted of one or more criminal offenses. (b) The specific duties and responsibilities necessarily related to the
license or employment sought or held by the person. (c) The bearing, if any, the criminal offense or offenses for which the
person was previously convicted will have on his fitness or ability to perform one or more such duties or responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his rehabilitation and good conduct.
(h) The legitimate interest of the public agency or private employer in protecting property, and the safety and welfare of
specific individuals or the general public.
2. In making a determination pursuant to section seven hundred fifty-two of this chapter, the public agency or private employer shall
also give consideration to a certificate of relief from disabilities or a certificate of good conduct issued to the applicant, which
certificate shall create a presumption of rehabilitation in regard to the offense or offenses specified therein.
754. Written statement upon denial of license or employment. At the request of any person previously convicted of one or more criminal
offenses who has been denied a license or employment, a public agency or private employer shall provide, within thirty days of a request, a
written statement setting forth the reasons for such denial.
755. Enforcement.
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a proceeding brought pursuant to
article seventy-eight of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by the division of human rights
pursuant to the powers and procedures set forth in article fifteen of the executive law, and, concurrently, by the New York city
commission on human rights.
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ADP totalSOURCE
The ADP logo, ADP, ADP TotalSource, My TotalSource and In The Business of Your
Success are registered trademarks of ADP, Inc. FS104 Copyright 2013 ADP, Inc.