INSTRUCTIONS FOR COMPLETING NEW HIRE PAPERWORK

1. EMPLOYMENT AFTER RETIREMENT ACKNOWLEDGEMENT FORMo Please read and sign the acknowledgment form agreeing to read the Teacher Retirement System of Texas Guide

prior to your start date and periodically thereafter.

2. ADDITIONAL INFORMATION SHEET:e Must be LEGIBLE, PLEASE PRINT.e Make sure that you have checked the "CAN" or "CANNOT" be given to the public box at the bottom of the page.

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I - 9 EMPLOYMENT ELIGIBILITY VERIFICATION:Complete SECTION 1ONLY, then sign and date it. You will need to bring TWO FORMS OF ID with you to the newhire meeting session. Please see the LIST OF ACCEPTABLE DOCUMENTS (attached) for employment eligibilityverification.

4. W-4Form:

® It is NOT a requirement that you complete the Personal Allowances Worksheet attached.• LINE 5 at the bottom must have a number in it. "0" means you want the MOSTtaxes taken out of your

paycheck. YOU will need to consult someone (parent, spouse, accountant) if you are unsure.

o Please make sure to sign and date this form.

5. AUTHORIZATION FOR DIRECT DEPOSIT (OPTIONAL):o Please complete this form by checking "NEW" and filling in ALL appropriate information and attaching a VOIDED

CHECK.

6. SOCIAL SECURITY FORM SSA - 1945:o Please read carefully. If you have any questions, consult the Social Security Office at the number or website

listed on the form.

• Make sure your NAME and Social Security # is listed at the top of this form.® You must retain a copy of this form for your records

7. INSURANCE NOTIFICATION FORM:• You may view benefits information at WWW.katyisd.org -Departments -Risk Management - Benefits for

additional information.• Your health coverage is effective the first of the month following your first day of employment.

8. EMPLOYMENT JOB DESCRIPTION:e To be completed by TEACHERS ONLY (I.E. Elementary or Secondary teaching staff only).

NOTE:FINGERPRINTING:

o Fingerprinting is mandatory and must be completed prior to the New Hire meeting, (*NOTE: If youhave already completed fingerprinting, please disregard this notice).

® Verification of completed fingerprinting and receipt from MorphoTrust USA is requested to bepresented at the new hire meeting. (*NOTE: This is for newly fingerprinted employees only).

15 - 16 Elementary New Hire Paperwork

KATY INDEPENDENT SCHOOL DISTRICT

Employment after Retirement Acknowledgement Form

I agree to read the Teacher Retirement System of Texas (TRS) Employment after Retirement

Guide (www.trs.state.tx.us), prior to my start date, and to abide by the standards, policies, and

procedures defined within or referenced in the document.

As this information is subject to change, I understand that it is my responsibility as a retiree to

stay current on all updates and to comply with any changes in TRS policies and procedures,

I UNDERSTAND THAT SPECIAL ATTENTION MUST BE GIVEN TO RESTRICTIONS REGARDINGASSIGNMENTS AND WORK HOURS, AS STIPULATED BY TRS, ESPECIALLY WITH REGARD TOWORKING IN VACANT OR SUPPLEMENTAL POSITIONS AND WORKING IN MULTIPLE SCHOOLDISTRICTS.

I UNDERSTAND THAT ANY VIOLATION OF THESE RESTRICTIONS MAY RESULT IN THEREVOCATION OF MY ANNUITY BYTRS. I ACKNOWLEDGE THAT I AM SOLELY RESPONSIBLE FORANY REPAYMENTS TO TRS THAT MAY RESULT FROM ANY SUCH VIOLATIONS.

I UNDERSTAND THAT I WILL NOT BE EMPLOYED IN ANY CAPACITY BY KATY ISD UNTIL I HAVEBEEN RETIRED FROM ALL TRS-COVERED EMPLOYERS FOR 12 FULL, CONSECUTIVE CALENDARMONTHS.

My signature below affirms that I have retired with TRS, and I have not worked in any

capacity for a TRS-covered employer for 12 full, consecutive calendar months. I also agree to

pay any and all fines, penalties, and any other member charges imposed by TRS for any

reason and hold Katy ISD harmless for any and all existing and/or future charges.

PRINT NAME

SIGNATURE

DATE

* Any further questions or inquiries regarding TRS regulations and guidelines should be directed to:

Teacher Retirement System of Texas (TRS)1000 Red River StreetAustin, TX 78701-2698

1-800-223-8778

www.trs.state.tx.us

KATY INDEPENDENT SCHOOL DISTRICT

Additional Information Sheet

Full Name (please print)

Last Name First Name Middle Name(DO NOT USE INITIALS)

Social Security Number Date of BirthMaleÿ Female__

.... / /

Address

/ / /P.O. Box or Street City ST ZipPhone Number Marital Status

[] home(, .) -- [] cell S__ M D W

The United States Department of Education (USDE) requires all state and local education institutions tocollect data on ethnicity and race for students and staff. This information is used for state and federalaccountability reporting, as well as for reporting to the Office of Civil Rights (OCR) and the EqualEmployment Opportunity Commission (EEOC). (Please complete both Part I and Part 2.)

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

Part 1 - Ethnicity (choose only onel Part 2 - Race (choose one ormorel

[] Hispanic/Latino(a person of Cuban, Mexican, Puerto Rican,South or Central American or other Spanishculture or origin, regardless of race)

[] Not Hispanic/Latino

Must complete Part 2 =ÿ

[] American Indian or Alaska Native(a person having origins in any of the original peoples of North or South America(including Central America), and who maintains a tribal affiliation or communityattachment)

[] Asian(a person having origins in any of the original peoples of the Far East, SoutheastAsia or the Indian subcontinent including, but not limited to, Cambodia, China, India,Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam)

[] Black or African American(a person having origins in any of the black racial groups of Africa)

[] Native Hawaiian or other Pacific Islander(a person having origins in any of the original peoples of Hawaii, Guam, Samoa orother Pacific Islands)

[] White(a person having origins in any of the original peoples of Europe, the Middle East orNorth Africa)

Statement of Confidentiality

According to the Open Records Act (effective 9/1/85) the home addresses, home telephone numbers (including formerhome addresses and telephone numbers), social security numbers and any information that reveals whether the personhas family members are confidential if the individual has, in writing, opted to keep this information closed. As anemployee of KISD, you may indicate whether you wish this information to be released by completing the appropriate boxbelow. Failure to complete either box below indicates that you have no objection to having this information released.You can file a new form at any time to reflect a change in your choice concerning confidentiality.

My home address, home telephone number (including former home addresses and telephone numbers), socialsecurity number and any information that reveals whether I have family members: (check one)

CAN BE GIVEN to the public CANNOT BE GIVEN to the public

Signature Date

Updated: April 2013

Instructions for Employment Eligibility Verification uscIsForm I-9

Department of Homeland Security OMB No. 1615-0047U.S. Citizenship and Immigration Services Expires 03/31/2016

Read all instructions carefully before completing this form.

Anti-Discrimination Notice. It is 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 onthat individual's citizenship status, immigration status or national origin. Employers CANNOT specify whichdocument(s) they will accept fi'om an employee. The refusal to hire an individual because the documentation presentedhas a future expiration date may also constitute illegal discrimination. For more information, call the Office of SpecialCounsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155(employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc.

Employers must complete Form I-9 to document verification of the identity and employment authorization of each newemployee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealthof the Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity andemployment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employersshould 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, including those recruiters and referrers for a fee who are agricultural associations,agricultural employers, or farm labor contractors.

Folÿ I-9 is made up of three sections. Employers may be fined if the form is not complete. Employers are responsible forretaining completed forms. Do not mail completed forms to U.S. Citizenship and Immigration Services (USCIS) orImmigration and Customs Enforcement (ICE).

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Newly hired employees must complete and sign Section 1 of Form I-9 no later than tile 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 initial. Your last name is your family name orsurname. If you have two last names or a hyphenated last name, include both names in the last name field. Your firstname is your given name. Your middle initial is the first letter of your second given name, or the first letter of yourmiddle name, if any.

Other names used: Provide all other names used, if any (including maiden name). If you have had no other legalnames, write "N/A."

Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (ifapplicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commutersfrom Canada or Mexico may use an international address in this field.

Date of Birth: Provide your date of birth in the mm/dd/yyyy format. For example, January 23, 1950, should bewritten as 01/23/1950.

U.S. Social Security Number: Provide your 9-digit Social Security number. Providing your Social Security numberis voluntary. However, if your employer participates in E-Verify, you must provide your Social Security number.

E-mail Address and Telephone Number (Optional): You may provide your e-mail address and telephonenumber. Depmÿment of Homeland Security (DHS) may contact you if DHS learns of a potential mismatch betweenthe information provided and the information in DHS or Social Security Administration (SSA) records. You may write"N/A" if you choose not to provide this information.

EMPLOYERS MUST RETAIN COMPLETED FORM I-9Form I-9 Instructions 03/08/13 N DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS Page 1 of 9

All employees must attest in Section 1, under penalty of perjury, to their citizenship or immigration status by checkingone of the following four boxes provided on the form:

lo

2.

A citizen of the United States

A noncitizen national of the United States: Noncitizen nationals of the United States are persons born in AmericanSamoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizennationals born abroad.

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who residesin 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 RegistrationNumber (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is thesame 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 doesnot expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of theMarshall 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 thesame as your A-Number without the "A" prefix. If you have not received an A-NumberAJSCIS Number, recordyour Admission Number. You can find your Admission Number on Form 1-94, "Arrival-Departure Record," or asdirected 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, thenalso record information about the foreign passport you used to enter the United States (number and country ofissuance).

(2) If you obtained your admission number from USCIS within the United States, or you entered the United Stateswithout a foreign passport, you must write "N/A" in the Foreign Passport Number and Count13, of Issuancefields.

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signingand dating this form, you attest that the citizenship or immigration status you selected is con'ect and that you are awarethat you may be imprisoned and/or fined for making false statements or using false documentation when completing thisform. To fully complete this form, you must present to your employer documentation that establishes your identity andemployment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on thelast 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 if the employee requires assistance to complete Section 1(e.g., the employee needs the instructions or responses translated, someone other than the employee fills out theinformation blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement)

Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should reviewthe guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-2 74) on www.useis.gov/I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannotpresent an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling outSection 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.

Form I-9 Instructions 03/08/13 N Page 2 of 9

Se:efioÿ2;!iilEmplÿyÿrorÿuthoiÿized:Representatiÿe:Rev[eÿ: and VerifieatiOn ,:i [Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers maynot ask an individual to complete Section 1 before he or she has accepted a job offer.

Employers or their authorized representative must complete Section 2 by examining evidence of identity and employmentauthorization within 3 business days of the employee's first day of employment. For example, if an employee beginsemployment on Monday, the employer must complete Section 2 by Thursday of that week. However, if an employer hiresan individual for less than 3 business days, Section 2 must be completed no later than the first day of employment. Anemployer may complete Form I-9 before the first day of employment if the employer has offered the individual a job andthe individual has accepted.

Employers cannot specify which document(s) employees may present from the Lists of Acceptable Documents, found onthe last page of Form I-9, to establish identity and employment authorization. Employees must present one selection fromList A OR a combination of one selection from List B and one selection fi'om List C. List A contains documents thatshow both identity and employment authorization. Some List A documents are combination documents. The employeemust present combination documents together to be considered a List A document. For example, a foreign passport and aForm 1-94 containing an endorsement of the alien's nonimmigrant status must be presented together to be considered aList A document. List B contains documents that show identity only, and List C contains documents that showemployment authorization only. If an employee presents a List A document, he or she should not present a List B and ListC document, and vice versa. If an employer participates in E-Verify, the List B document must include a photograph.

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, thatthe employee entered in Section 1. This will help to identify the pages &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 genuineand to relate to the person presenting it. The person who examines the documents must be the same person who signsSection 2. The examiner of the documents and the employee must both be physically present during the examinationof the employee's documents.

, Record the document title shown on the Lists of Acceptable Documents, issuing authority, document number andexpiration date (if any) from the original document(s) the employee presents. You may write "N/A" in any unusedfields.

If the employee is a student or exchange visitor who presented a foreign passport with a Form 1-94, the employershould also enter in Section 2:

a. The student's Form 1-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number);and the program end date fi'om Form 1-20 or DS-2019,

3. Under Certification, enter the employee's first day of employment. Temporary staffing agencies may enter the first daythe employee was placed in a job pool. Recruiters and recruiters for a fee do not enter the employee's first day ofemployment.

4. Provide the name and title of the person completing Section 2 in the Signature of Employer or AuthorizedRepresentative field.

6,

7.

Sign and date the attestation on the date Section 2 is completed.

Record the employer's business name and address.

Return the employee's documentation.

Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they should bemade for ALL new hires or reverifications. Photocopies must be retained and presented with Form I-9 in case of aninspection by DHS or other federal government agency. Employers must always complete Section 2 even if theyphotocopy an employee's document(s). Making photocopies of an employee's document(s) cannot take the place ofcompleting Form I-9. Employers are still responsible for completing and retaining Form I-9.

Form I-9 Instructions 03/08/13 N Page 3 of 9

Unexpired Documents

Generally, only unexpired, original documentation is acceptable. The only exception is that an employee may present acertified copy of a birth certificate. Additionally, in some instances, a document that appears to be expired may beacceptable if the expiration date shown on the face of the document has been extended, such as for individuals withtemporary protected status. Refer to the Handbook for Employers: Instructions for Completing Form I-9 (M-274) or I-9Central (www.uscis.gov/I-9Central) for examples.

Receipts

If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt inlieu of a document from the Lists of Acceptable Documents on the last page of this form. Receipts showing that a personhas applied for an initial grant of employment authorization, or for renewal of employment authorization, are notacceptable. Employers calmot accept receipts if employment will last less than 3 days. Receipts are acceptable whencompleting 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 fi'ames describedbelow.

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. Theemployee must present the actual document within 90 days from the date of hire.

2. The an'ival polÿion of Form 1-94/I-94A with a temporary 1-551 stamp and a photograph of the individual. Theemployee must present the actual Permanent Resident Card (Form 1-551) by the expiration date of the temporary1-551 stamp, or, if there is no expiration date, within 1 year from the date of issue.

3. The departure portion of Form 1-94/I-94A with a refugee admission stamp. The employee must present an unexpiredEmployment Authorization Document (Form 1-766) or a combination of a List B document and an unrestricted Social

Security card within 90 days.

When the employee provides an acceptable receipt, the employer should:

1. Record the document title 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 that thereceipt 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.

See the Handbook for Employers: Instructions for Completing Form I-9 (M-274) at www.useis.gov/I-9Central for moreinformation on receipts.

Employers or their authorized representatives should complete Section 3 when reverifying that an employee is authorizedto work. When rehiring an employee within 3 years of the date Form I-9 was originally completed, employers have theoption to complete a new Form I-9 or complete Section 3. When completing Section 3 in either a reverification or rehiresituation, if the employee's nmne has changed, record the name change in Block A.

For employees who provide an employment authorization expiration date in Section 1, employers must reverifyemployment authorization on or before the date provided.

Form I-9 Instructions 03/08/13 N Page 4 of 9

Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whoseemployment authorization does not expire (e.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 topresent evidence of employment authorization in Section 2 that contains an expiration date and requires reverification,such as Form 1-766, Employment Authorization Document.

Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2expires. However, employers should not reverify:

1. U.S. citizens and noncitizen nationals; or

2. Lawful permanent residents who presented a Permanent Resident Card (Form 1-551) for Section 2.

Reverification does not apply to List B documents.

If both Section 1 and Section 2 indicate expiration dates triggering the reverification requirement, the employer shouldreverify by the earlier date.

For reverification, an employee must present unexpired documentation from either List A or List C showing he or she isstill authorized to work. Employers CANNOT require the employee to present a particular document fi'om List A or ListC. 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 ofrehire if you rehire an employee within 3 years of the date this form was originallycompleted, 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 C if:

,

a. The employment authorization or employment authorization document of a current employee is about to expire andrequires reverification; or

b. You rehire an employee within 3 years of the date this form was originally completed and his or her employmentauthorization or employment authorization document has expired. (Complete Block B for this employee as well.)

To complete Block C:

a. Examine either a List A or List C document the employee presents that shows that the employee is currentlyauthorized to work in 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, employers may either complete Section 3 of a new Form I-9 or Section 3 of the previouslycompleted Form I-9. Any new pages of Form I-9 completed during reverification must be attached to the employee'soriginal Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containingSection 3, with the employee's name entered at the top of the page, to the employee's original Form I-9. If there is amore current version of Form I-9 at the time of reverification, you must complete Section 3 of that version of the form.

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There is no fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must beretained by the employer and made available for inspection by U.S. Government officials as specified in the "USCISPrivacy Act Statement" below.

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For more detailed information about completing Form I-9, employers and employees should refer to the Handbook forEmployers: Instructions for Completing Folÿn 1-9 (M-274).

Form I-9 Instructions 03/08/13 N Page 5 of 9

You can also obtain information about Form I-9 fi'om the USCIS Web site at www.uscis.gov/I-9Central, by e-mailingUSCIS at I-9Central@dhs.gov, 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/forms. You may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain formsand information by contacting the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearingimpaired), call 1-800-767-1833,

Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify theemployment eligibility of their newly hired employees, can be obtained from the USCIS Web site at www.dhs.gov/E-Veriÿ, by e-mailing USCIS at E-Verify@dhs.gov or by calling 1-888-464-4218. For TDD (hearing impaired), call1-877-875-6028.

Employees with questions about Form I-9 and/or E-Verify can reach the USCIS employee hotline by calling1-888-897-7781. For TDD (hearing impaired), call 1-877-875-6028.

IA blank Form I-9 may be reproduced, provided all sides are copied. The instructions and Lists of Acceptable Documentsmust be available to all employees completing this form. Employers must retain each employee's completed Form I-9 foras long as the individual works for the employer. Employers are required to retain the pages of the form on which theemployee and employer enter data. If copies of documentation presented by the employee are made, those copies mustalso be kept with the form. Once the individual's employment ends, the employer must retain this form for either 3 yearsafter the date of hire or 1 year after the date employment ended, whichever is later.

Form I-9 may be signed and retained electronically, in compliance with Depalÿment of Homeland Security regulations at8 CFR 274a.2.

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AUTHORITIES: The authority for collecting this information is the Immigration Reform and Control Act of 1986,Public Law 99-603 (8 USC 1324a).

1

PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform andControl Act of 1986. This law requires that employers verify the identity and employment authorization of individualsthey hire for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are notauthorized to work in the United States.

DISCLOSURE: Submission of the information required in this form is voluntary. However, failure of the employer toensure proper completion of this form for each employee may result in the imposition of civil or criminal penalties. Inaddition, employing individuals knowing that they are unauthorized to work in the United States may subject theemployer to civil and/or criminal penalties.

ROUTINE USES: This information will be used by employers as a record of their basis for determining eligibility of anemployee to work in the United States. The employer will keep this form and make it available for inspection byauthorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel forImmigration-Related Unfair Employment Practices.

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An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection ofinformation unless it displays a currently valid OMB control number. The public reporting burden for this collection ofinformation is estimated at 35 minutes per response, including the time for reviewing instructions and completing andretaining 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 Selwices, Regulatory CoordinationDivision, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No.1615-0047. Do not mail your completed Form 1-9 to this address.

Form I-9 Instructions 03/08/13 N Page 6 of 9

Employment Eligibility Verification USCISForm I-9

Department of Homeland Security OMB No. 1615-0047U,S. Citizenship and Immigration Services Expires 03/31/2016

-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 whichdocument(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a futureexpiration date may also constitute illegal discrimination.

section 1. Employee Information and Attestation (Employees must complete and sign Section i of Form I-9 no laterthanÿthe 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 inconnection 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)(See instructions)

For afiens authorized to work, provide your Alien Registration Number/USCIS Number OR Form 1-94 Admission Number:

1. Alien Registration Number/USCIS Number:

OR2. Form 1-94 Admission Number:

. Some aliens may write "N/A" in this field.

3-D BarcodeDo Not Write in This Space

If you obtained your admission number from CBP in connection with your arrival in the UnitedStates, include the following:

Foreign Passport Number:

Country of Issuance:

Some aliens may write "N/A" on the Foreign Passport Number and Country of Issuance fields. (See instructions)

Signature of Employee: Date (mm/dd/yyyy):

prepared by a persoo other than the Ii i:: I

I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge theinformation is true and correct.

Signature of Preparer or Translator: Date (mm/dd/yyyy):

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

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

i:ii!:i eÿ Comple[teÿNext ÿge:!! ::]

Form I-9 03/08/13 N Page 7 of 9

n

Section 2. Employer or Authorized Representative Review andVerificati0n(Emp/oyere or their authorized representative must comp/ete and Sign Section 2 within 3 business days Of the emp/oyee's first day of emp/oymant. Youmust physica//y examine one document from'List A OR examine a combination of one document from List B and one document from List C as/isted onthe "Lists of Acceptab/e Documents" on the next page of this form. For each document you review/record the fo/Iowing information: document tit/e,issuing authority, document number, and expiration date, if any.).. ....

Employee Last Name, First Name and Middle Initial from Section 1:

List A AND List CIdentity and Employment Authorization Employment Authorization

Document Title: Document Title:

Issuing Authority:

Document Number:

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

Document Title:

Issuing Authority:

Document Number:

Expiration Date (ifany)(mm/dd/yyyy):

Document Title:

Issuing Authority:

Document Number:

Expiration Date (if any)(mm/dd,4/yyy):

OR List BIdentity

Document Title:

Issuing Authority:

Document Number:

Expiration Date (ifany)(mm/dd/yyyy):

iiÿ

Issuing Authority:

Document Number:

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

3-D BarcodeDo Not Write in This Space

CertificationI attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) theabove-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge theemployee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):

Signature of Employer or Authorized Representative Date (mm/dd/yyyy)

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

(See instructions for exemptions.)

Title of Employer or Authorized Representative

Human Resources Representative

Employer's Business or Organization Name

Katy Independent School District

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

6301 S. Stadium Lane Katy

State Zip Code

TX 77494

Section 3, Reverification and Rehires, (To be Completed and signed bY empioyer or authorized representative,)A. New Name (if applicable) Last Name (Family Name) First Name (Given Name) Middle Initial B. Date of Rehire fifapplicable) (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 employeepresented that establishes current employment authorization in the space provided below.

Document Title: Document Number: Expiration Date (ifany)(mm/dd/yyyy):

attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and ifthe employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

I Signature of Employer or Authorized Representative: Date(mm/dd/YYYY):lPrintNameofEmpl°yer°rAuth°rizedRepresentative: IFormI-9 03/08/13 N Page 8 of 9

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

Employees may present one selection from List Aor a combination of one selection from List B and one selection from List C.

LISTADocuments that Establish

Both Identity andEmployment Authorization

LIST BDocuments that Establish

Identity

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

2. Permanent Resident Card or AlienRegistration Receipt Card (Form 1-551

6,

5,

4.

Foreign passport that contains atemporary 1-551 stamp or temporary1-551 printed notation on a machine-readable immigrant visa

Employment Authorization Documentthat contains a photograph (Form1-766)

For a nonimmigrant alien authorizedto work for a specific employerbecause of his or her status:

a. Foreign passport; and

b. Form 1-94 or Form 1-94A that hasthe following:

(1) The same name as the passport;and

(2) An endorsement of the alien'snonimmigrant status as long asthat period of endorsement hasnot yet expired and theproposed employment is not inconflict with any restrictions orlimitations identified on the form.

Passport from the Federated States ofMicronesia (FSM) or the Republic ofthe Marshall Islands (RMI) with Form1-94 or Form 1-94A indicatingnonimmigrant admission under theCompact of Free Association Betweenthe United States and the FSM or RMI

3,

AND

LIST CDocuments that EstablishEmployment Authorization

1,

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

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

6. Military dependent's ID card

7. U.S. Coast Guard Merchant MarinerCard

8. Native American tribal document

9. Driver's license issued by a Canadiangovernment authority

For persons under age 18 who areunable to present a document

listed above:

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Driver's license or ID card issued by aState or outlying possession of theUnited States provided it contains aphotograph or information such asname, date of birth, gender, height, eyecolor, and address

1,

2,

3,

4,

5. Native American tribal document

6. U.S. Citizen ID Card (Form 1-197)

7. Identification Card for Use ofResident Citizen in the UnitedStates (Form I-179)

8. Employment authorizationdocument issued by theDepartment of Homeland Security

A Social Security Account Numbercard, unless the card includes one ofthe following restrictions:(1) NOT VALID FOR EMPLOYMENT

(2) VALID FOR WORK ONLY WITHINS AUTHORIZATION

(3) VALID FOR WORK ONLY WITHDHS AUTHORIZATION

Certification of Birth Abroad issuedby the Department of State (FormFS-545)

Certification of Report of Birthissued by the Department of State(Form DS-1350)

Original or certified copy of birthcertificate issued by a State,county, municipal authority, orterritory of the United Statesbearing an official seal

Illustrations 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 Reviewand Verification," for more information about acceptable receipts,

Form I-9 03/08/13 N Page 9 of 9

Form W4 (2015)Purpose. Complete Form W-4 so that your employercan withhold the correct federal Income tax from yourpay. Consider completing a new Form W-4 each yearand when your personal or financial situation changes.

Exemption from withholding, If you are exempt,complete only lines 1,2, 3, 4, and 7 and sign the formto validate it. Your exemption for 2015 expiresFebruary 16, 2016. See Pub. 505, Tax Withholdingand Estimated Tax.

Note. If another person can claim you as a dependenton his or her tax return, you cannot claim exemptionfrom withholding if your income exceeds $1,050 andincludes more than $350 of unearned income (forexample, interest and dividends).

Exceptions. An employee may be able to claimexemption from withholding even if the employee is adependent, if the employee:

+ Is age 65 or older,

+ Is blind, or

• Will claim adjustments to income; tax credits; oritemized deductions, on his or her tax return.

The exceptions do not apply to supplemental wagesgreater than $1,000,000.

Basic instructions. If you are not exempt, completethe Personal Allowances Worksheet below. Theworksheets on page 2 further adjust yourwithholding allowances based on itemizeddeductions, certain credits, adjustments to income,or two+earners/multiple jobs situations.

Complete all worksheets that apply. However, youmay claim fewer (or zero) allowances. For regularwages, withholding must be based on allowancesyou claimed and may not be a flat amount orpercentage of wages+

Head of household. Generally, you can claim headof household filing status on your tax return only ifyou are unmarried and pay more than 50% of thecosts of keeping up a home for yourself and yourdependent(s) or other qualifying individuals. SeePub. 501, Exemptions, Standard Deduction, andFiling Information, for information.

Tax credits, You can take projected tax credits into accountin figuring your allowable number of withholding allowances.Credits for child or dependent care expenses and the childtax credit may be claimed using the Personal AllowancesWorksheet below. See Pub. 505 for information onconverting your other credits into withholding allowances.

Nonwage income. If you tlave a targe amount ofnonwage income, such as interest or dividends,consider making estimated tax payments using Form1040-ES, Estimated Tax for Individuals. Otherwise, youmay owe additional tax. If you have pension or annuityincome, see Pub. 505 to find out if you should adjustyour withholding on Form W-4 or W-4P.

Two earners or multiple jobs, If you have aworking spouse or more than one job, figure thetotal number of allowances you are entitled to claimon all jobs using worksheets from only one FormW-4. Your withholding usually will be most accuratewhen all allowances are claimed on the Form W-4for the highest paying job and zero allowances areclaimed on the others. See Pub. 505 for details.

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

Check your withholding. After your Form W-4 takeseffect, use Pub. 505 to see how the amount you arehaving withheld compares to your projected total taxfor 2015. See Pub. 505, especially if your earningsexceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any futuredevelopments affecting Form W-4 (such as legislationenacted after we release it) will be posted at www.irs.gov/w4.

A

B

DEF

G

Personal Allowances Worksheet (Keep for your records.)Enter "1" for yourself if no one else can claim you as a dependent .................. A

{ . You are single and have only one job; or }Enter "1" if: + You are married, have only one job, and your spouse does not work; or B

• Your wages from a second job or your spouse's wages (or the total of both) are $1,500 or less,Enter "1" for your spouse. But, you may choose to enter "-0-" if you are married and have either a working spouse or morethan one job, (Entering "-0-" may help you avoid having too little tax withheld.) .............. C

Enter number of dependents (other than your spouse or yourself) you will claim on your tax return ........ DEnter "1" if you will file as head of household on your tax return (see conditions under Head of household above) EEnter "1" if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit F(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)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 ($100,000 if married), enter "2" for each eligible child; then less "1" if youhave two to four eligible children or less "2" if you have five or more eligible children.,, If your total income will be between $65,000 and $84,000 ($100,000 and $119,000 if married), enter "1" for each eligible child. G

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,) ÿ- H

o If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the DeductionsFor 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 combinedworksheets earnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 tothat 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. - .................................

DepartmentE°rm WIll4Io, the Treasury EM Pl°Yÿ]ÿe Vs Withh°lding AI I°wancÿ]ÿ CeÿtifJcateyou are a or exemption withholding OMÿNo. 15ÿ5-0574(ÿ" Whether entitled to claim certain number of allowances from isInternal 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

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

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

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

check here. You must call 1-800-772-1218 for a replacement card. ÿ []

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) J5J6 Additional amount, if any, you want withheld from each paycheck ..............' '1615

7 I claim exemption from withholding for 2015, and I certify that I meet both of the following conditions for exemption. }/

* Last year t 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 ............... ÿ I 7 l

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

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

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

IFor Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2015)

Form W-4 (2015)

Note.Deductions and Adjustments Worksheet

Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income,1 Enter an estimate of your 2015 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1951) of yourincome, and miscellaneous deductions, For 2015, you may have to reduce your itemized deductions if your income is over $309,900and you are married filing jointly or are a qualifying widow(er); $284,050 if you are head of household; $258,250 if you are single and nothead of household or a qualifying widow(er); or $154,950 if you are married filing separately. See Pub. 505 for details .... 1 $

{ $12,6001f married flling jointly or qualifying widow(er) }2 Enter; $9,250 if head of household ........... 2 $

$6,300 if single or married filing separately3 Subtract line 2 from line 1, If zero or less, enter "-0-" + ............... 3 $

4 Enter an estimate of your 2015 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total, (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2015 Form W-4 worksheet in Pub. 505,) ............ 5 $

Enter an estimate of your 2015 nonwage income (such as dividends or interest) ........ 6 $Subtract line 6 from line 5. If zero or less, enter "-0-" , ............... 7 $

Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction ....... 8Enter the number from the Personal Allowances Worksheet, line H, page 1 ......... 9

Add lines 8 and 9 and enter the total here, If you plan to use the Two-Earners/Multiple Jobs Worksheet,also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1

Page 2

6789

10

Note.

12

10Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1 .)

Use this worksheet only if the instructions under line H on page 1 direct you here,Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, ifyou are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter morethan "3" , .............................

Note.

2

33 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 .........

If line 1 is less than line 2, enter "-0-" on Form W-4, line 5, page 1, Complete lines 4 through 9 below tofigure 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 2015. 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 2015. Enterthe 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 2Married Filing Jointly All Others All Others

Enter on Enter online 2 above line 2 above

If wagesfrom LOWESTpayingjob are-

$0 - $8,0008,001 - 17,00017,001 - 26,000

26,001 - 34,00034,001 - 44,00044,001 - 75,00075,001 - 85,00085,001 - 110,000

110,001 - t25,000125,001 - 140,000140,001 and over

0123456789

10

Married Filing Jointly

If wages from HIGHESTpaying job are--

So - $75,00075,001 - 135,000

135,001 - 205,000205,001 - 360,000360,001 - 405,000

405,001 and over

Enter online 7 above

$6001,ooo1,12o1,32o1,4oo1,58o

0123456789

lO1112131415

Ifwagesfmm LOWESTpayingjob am-

S0 - $6,0006,001 - 13,000

13,001 - 24,00024,001 - 26,00026,001 - 34,00034,001 44,00044,001 - 50,00050,001 - 65,00065,001 - 75,00075,001 - 80,00080,001 - 100,000

100,001 - 115,000115,001 - 130,000130,001 - 140,000140,001 - 150,000150,001 and over

If wagesfrom HIGHESTpayingjob are--

So - $38,00038,001 - 83,00083,001 - 180,000

180,001 - 395,000395,001 and over

Enteronline 7 above

$6001,0001,1201,3201,580

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on thisform to carry out the Internal Revenue laws of the United States, Internal Revenue Codesections 3402(0(2) and 6109 and their regulations require you to provide this information; youremployer uses it to determine your federal Income tax withholding, Failure to provide aproperly completed form will result In your being treated as a single person who claims nowithholding allowances; providing fraudulent information may subject you to penalties, Routineuses of this information include giving it to the Department of Justice for civil and criminallitigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessionsfor use In administering their tax laws; and to the Department of Health and Human Servicesfor use in the National Directory of New Hires, We may also disclose this information to othercountries under a tax treaty, to federal and state agencies to enforce federal nontax criminallaws, or to federal law enforcement and intelligence agencies to combat terrorism,

You are not required to provide the information requested on a form that is subject to thePaperwork Reduction Act unless the form displays a valid OMB control number, Books orrecords relating to a form or its Instructions must be retained as long as their contents maybecome material in the administration of any Internal Revenue law, Generally, tax returns andreturn information are confidential, as required by Code section 6103,

The average time and expenses required to complete and file this form will vary dependingon Individual circumstances, For estimated averages, see the instructions for your income taxreturn,

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

Katy Independent School District

AUTHORIZATION AGREEMENT FOR PAYROLL DIRECT DEPOSITPlease fill out one form per deposit account

Type of Transaction

IEW - Establish first time direct deposit

CHANGE - Update my previous deposit

CANCEL- Stop my payroll deposit

Please be advised that establishing a new deposit, or changing

an existing deposit, will require at least two payroll cycles to

take effect. You will receive a live paycheck mailed to your home

laddress until your direct deposit is in effect.

EMPLOYEE NAME:I authorize Katy ISD to transfer my paycheck directly to the financial institution(s) noted

below for deposit:

Direct Deposit Account NETAmount: NETAMOUNTDirect Deposit Account 2: ÿ AmountDirect Deposit Account 3: ÿ . Amount

CheckingCheckingChecking

Savings

Savings

Savings

Financial Institution

Transit/ABA Number Routing Number

City State IZip

Employee's Bank Account Number

II

This authorization will remain in effect until Katy ISD has received written notification from me that it is to beterminated, or when Katy ISD is notified by your financial institution of a change. Ten days notice is required for an

employee to terminate their deposit.

I understand that Katy ISD may make adjustments to my account at the financial institution(s) listed above in the even1of an over deposit. I further acknowledge that while the District does not anticipate any delays in the receipt of mÿ/direct deposit, in the event that a delay does occur, the District is not responsible for any inconvenience orcharges caused by such delay.

Signature Date Print Name

Please Attach a voided Check or statement from bank verifying account number

IISSN Katy ID Number Campus/Dept

Attach Check HerePlease tape check, no staples

1Revised 5/20/2011

Statement Concerning Your Employment in a JobNot Covered by Social Security

Employee Name

Employer Name KATY I.S.D.

Employee liD#

Employer ID# 74-6001484

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, youmay receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from SocialSecurity based on either your own work or the work of your husband or wife, or former husband or wife, yourpension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, willnot be affected. Under the Social Security law, there are two ways your Social Security benefit amount may beaffected.

Windfall Elimination ProvisionUnder the Windfall Elimination Provision, your Social Security retirement or disability benefit is figuredusing amodified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. Asa result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. Forexample, if you are age 62 in 2005, the maximum monthly reduction in your Social Security benefit as a result ofthis 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, "WindfallElimination Provision."

Government Pension Offset ProvisionUnder the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which youbecome entitled will be offs.et if you also receive a Federal, State or local government pension based on workwhere you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse orwidow(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 areeligible 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 stilleligible for Medicare at age 65. For additional information, please refer to Social Secmity Publication, "GovernmentPension Offset"

For More InformationSocial 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 ofhearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of theWindfall Elimination Provision and the Government Pension Offset Provision on my potential future SocialSecurity benefits.

Signature of Employee Date

Form SSA-1945 (12-2004)

Information about Social Security Form SSA-1945Statement 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 Stateand local government employers to provide a statement to employees hired January 1, 2005 or later in a job notcovered under Social Security. The statement explains how a pension from that job could affect future SocialSecurity benefits to which they may become entitled.

Form SSA-1945, Statement Concerning Your Employment in a Job Not Covered by Social Security, is thedocument that employers should use to meet the requirements of the law. The SSA-1945 explains the potentialeffects of two provisions in the Social Security law for workers who also receive a pension based on their work ina job not covered by Social Security. The Windfall Elimination Provision can affect the amount of a worker'sSocial Security retirement or disability benefit. The Government Pension Offset Provision can affect a SocialSecurity benefit received as a spouse or an ex-spouse.

Employers must:

e 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.gov/form1945.Paper copies can be requested by email at oplm.oswm.rqct.orders@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

a post office box. Also, if appropriate, include the name of the person to whom the forms are to be delivered. Theforms are available in packages of 25. Please refer to Inventory Control Number (ICN) 276950 when ordering.

Form SSA°1945 (12-2004)

Katy Independent School District

Mike RobinsonDIÿGTOR OP RISK MÿkN'AGEICLF.NT

Dear Employee:

Several voluntary benefits are available to you as a benefit eligible Katy I.S.D. employee. Those benefits

include medical, dental, vision, life, disability, cancer, and legal protection plans. These benefits are ex-

plained at benefit meetings held by the Risk Management Department. You may register to attendone of the upcoming benefits meetings (Newly Benefits Eligible Information Meetings) by goingonline to ÿ. Click on "Departments" located on the left side of the Katy ISDhome page. You will then be able to scroll down to District Services where you will be ableto access the Insurance/Risk Management website allowing you to register for benefits meet-ings. Benefit information can be obtained by accessing the Katy Benefits website at www.lcatybenefirs.

org. This is also the site where you may enroll or you may call 1-866-222-IÿSD if you wish to enroll byphone. Once your personal information is in the Katy Benefits system, you will receive an em'ollment

packet at your home. Because you will receive the packet at your home it is very important that you give

the most accurate address to Human Resources. Once you receive your packet you may either enroll

by going online at www.katybenefits.org or by calling 1-866-222-KISD. You are eligible to participatein any of the available benefits effective on the first day of the month following the first day worked orfirst day benefits eligible. If the first day worked or benefits eligible is the first day of the month, yourbenefits will be effective on that daTÿ You must enroll within one month of your eligibility date in orderto participate in any voluntary benefits. Premiums will be payroll deducted from your effective datewhich could be prior to your actual enrollment. If you do not enroll within the first month of eligibil-ity you will only have Basic Life coverage. This coverage is provided by the district with no cost to the

employee. In most cases, the amount is $20,000.

After reading this letter, please sign below,

I understand that I am responsible for my enrollment by the date specified in the benefit packet.

Signature Social Security # Date

If you have questions regarding your benefits, you may call 1-866-222-KISD.

Welcome to Katy ISD,

Jo Arm TiltonInsurance Coordinator

Katy Independent School District . 6301 Soutk Stadium Lane . PO Box 159 . Katy, Texas 77492-0159

WHITE COPY: Insuranoo 281-396-2241 • Faÿ. 281-396-6142. wlUiararoblnson@katyisd.org

YELLOW COPY: Human Resources

New Health insurance Marketpnace CoverageOptiortsand Your Health Coverage

Form ApprovedOMB No. 1210-0149(expires 11-30-2013)

PART A: General nformationWhen key parts of the health care law take effect in 201 4, there will be a new way to buy health insurance: the HealthInsurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basicinformation about the new Marketplace and employment-based health coverage offered by your employer.

What is the Health Insurance Marketplace'?.

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. TheMarketplace offers "one-stop shopping" to find and compare private health insurance options. You may also be eligiblefor a new kind of tax credit that lowers your monthly premium right away. Open enrollment for health insurancecoverage through the Marketplace begins in October 2013 for coverage starting as early as January 1, 201 4.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, oroffers coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends onyour household income.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligiblefor a tax credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may beeligible for a tax credit that lowers your monthly premium, or a reduction in certain cost-sharing if your employer doesnot offer coverage to you at all or does not offer coverage that meets certain standards. If the cost of a plan from your

employer that would cover you (and not any other members of your family) is more than 9.5% of your householdincome for the year, or if the coverage your employer provides does not meet the "minimum value" standard set by the

Affordable Care Act, you may be eligible for a tax credit.1

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

tax basis.

How Can I Get More Information?For more information about your coverage offered by your employer, please check your summary plan description orcontact Benefits Outlook at www.KatvBenefits.ora: 866-222-5473

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

EMPLOYMENTINFORMATION ONLY

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered

by the plan is no less than 60 percent of such costs,

PART B: information About Heanth Coverage Offered by Your EmployerThis section contains information about any health coverage offered by your employer. If you decide to complete anapplication for coverage in the Marketplace, you will be asked to provide this information. This information is numberedto correspond to the Marketplace application.

3. Employer name

Katy Independent School District5. Employer address

P O Box ;159"7, City

Katy10. Who can we contact about employee health coverage at this job?

Benefits Outlook - www.KatyBenefits.org

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

261-396-2241 N/A

4. Employer Identification Number(EIN)

74-6001484

6. Employer phone number281-396-6000

8. State 9. ZIP code

TX 77492

Here is some basic information about health coverage offered by this employer:o As your employer, we offer a health plan to:

[] All employees.

[] Some employees. Eligible employees are:

Regular employee (active or on a benefits-eligible leave approved by the district) and you are an active, contributingmember of Teacher Retirement System (TRS). You may also participate if you are retired from TRS and rehired by thedistrict into a benefits-eligible position.

With respect to dependents:[] We do offer coverage. Eligible dependents are:

Legal spouse (unless legally separated); child under age 26; unmarried child of any age, who is incapable ofself-support because of mental disability or physical handicap if declared as such before age 26; child who qualifies asyour dependent under the terms of a qualified medical child support order.

[] We do not offer coverage.

[] If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended tobe affordableÿ based on employee wages.

Even if your employer intends your coverage to be affordable, you may still be eligible for a premiumdiscount through the Marketplace. The Marketplace will use your household income, along with other factors,to determine whether you may be eligible for a premium discount. If, for example, your wages vary fromweek to week (perhaps you are an hourly employee or you work on a commission basis), if you are newlyemployed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process. Here's theemployer information you'll enter when you visit HealthCare.gov to find out if you can get a tax credit to lower yourmonthly premiums.

EMPLOYMENTINFORMATION ONLY

ELEMENTARY TEACHERS ONLY

KATY INDEPENDENT SCHOOL DISTRICT

Title:

Reports to:Duty Days:Wage/Hour Status:Pay Grade:Date Revised:

Teacher (0110) Elementary 1-5(0100) Kindergarten

PrincipalTen MonthsExemptTeacher Salary12-10

(0120) ESOL Elementary

Qualifications:

Bachelor's degree from accredited universityValid Texas teaching certificate with required endorsements for subject and level assignedAbility to instruct students and manage their behaviorStrong organizational, communication, and interpersonal skillsStudent teaching or approved internshipESOL certification requiredPhysically able to monitor student discipline and progress and to meet other student needs as requiredPhysically able to move about the room to perform formative assessments and facilitate small and large group instruction

Primary Purpose:

Provide students with appropriate learning activities and experiences designed to fulfill their potential for intellectual,emotional, physical, and social growth. Enable students to develop competencies and skills to function successfully in thefuture.

Major Responsibilities:

Instructional Strategies

1. Develop and implement engaging lesson plans that fulfill the requirements of district's curriculum programand show evidence of preparation using the district's automated curriculum as required by district policy.

2. Prepare lessons that reflect accommodations and differentiation for student learning styles.3. Present subject matter according to guidelines established by Texas Education Agency, board policies, and

administrative regulations.4. Collaborate with other members of staff for planning and implementing instructional goals, objectives, and

best practices according to district requirements.5. Design or adapt relevant learning experiences that incorporate digital tools and resources to promote student

learning and creativity.6. Assist in selection of books, equipment, and other instructional materials.

Student Growth and Development

1. Plan and use appropriate instructional strategies, assessment, activities, materials, and technology thatreflect accommodations for individual needs of students assigned.

2. Work cooperatively with special education teachers to modify curricula as needed for special education studentsaccording to guidelines established in Individual Education Plans (IEP).

3. Assist students in analyzing and improving study methods and habits.4. Consistently monitor student achievement through formal and informal assessment and use results to plan for

instructional delivery.5. Assume responsibility for extracurricular activities as assigned. Sponsor outside activities approved by the

campus principal.

Teacher Page 2

Classroom Management and Organization

1. Create classroom environment conducive to learning and appropriate for the physical, social, and emotionaldevelopment of a KISD student.

2. Manage student behavior and administer discipline according to Board policies, administrative regulations, theDiscipline Management Plan and Student Code of Conduct handbook and IEPs.

3. Take all necessary and reasonable precautions to protect students, equipment, materials, and facilities.

Communication

1. Establish and maintain open communication by conducting conferences with parents, students, principals, andteachers.

2. Maintain a professional relationship with colleagues, students, parents, and community members.3. Use acceptable communication skills to present information accurately and clearly.4. Present a positive role model for students, staff, parents, and community members by demonstrating behavior that is

professional, ethical, responsible, and aligned with the Professional Code of Ethics and Standard Practices for TexasEducators.

5. Articulate and provide support for the campus and district mission and goals to parents, colleagues, and communitymembers.

6. Demonstrate awareness of district/community needs and initiate activities to meet identified needs.7. Demonstrate the use of appropriate and effective techniques for engaging parents and the community.

Professional Growth and Development

1. Engage in and implement new learning from professional development activities correlated with teaching assignmentand with campus and district goals.

2. Keep informed of and comply with state, district, and school regulations and policies for classroom teachers.3. Compile, maintain, and file all physical and computerized reports, records, and other documents required.4. Attend and participate in faculty meetings and serve on staff committees as required.

Equipment Used:Interactive white board, computer, printer, copier, overhead projector, DVD/VCR, and other emerging technologies which areparticularly unique to the teaching assignment. Instructional and productivity software, as required by theteaching assignment.

Supervisory Responsibilities:Supervise instructional paraprofessionals, student teacher(s) assigned by the principal, and volunteers.

Working Conditions:Standing for long periods of time. Frequent stooping, bending, pulling and pushing, (e.g., replacing stacks of textbooks.media equipment, desks, and other classroom equipment/technology). The level of mobility required depends upon the gradelevel of teaching assignment and requirements thereof. Must maintain emotional control under stress.

The foregoing statements describe the general purpose and responsibilities assigned to this job and are not an exhaustivelist of all responsibilities and duties that may be assigned or skills that may be required.

Signature Date

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