District School Board of Pasco County Substitute

New Hire/Re-Hire Packet Dear Applicant:

This file contains a series of documents that you will need to review, complete and return so that we can set up your employee record. You will notice the documents are designed to allow for electronic signatures, but electronic signatures are not required. If you encounter any difficulties or choose not to use electronic signatures, you may print out and sign the forms, then return to Sub-Central via fax or email (see contact information below), or you may choose to bring a hard copy to your onboarding appointment, which will be scheduled once you have cleared fingerprinting. The forms contained here include:

Personal Information FormAssignment Preference Sheet Employee Information Exemption from Public Records New Hire FRS Declaration FormAuthorization/Agreement for Automatic Deposit of Payroll W-4 Employee Witholding Allowance Certificate Eligibility for Group Health Insurance Confidentiality Agreement Electronic Network Use Guidelines for EmployeesSchool Board Policy AcknowledgementTogether We Stand Acknowledgment Loyalty OathWorkers' Compensation Acknowledgement of Procedures Pasco's Ethical Standards Overview Acknowledgement Reasonable Suspicion Drug Testing Program AcknowledgementMandatory Reporting of Child Abuse AcknowledgementNotice of Social Security Number Disclosure Employment Not Covered by Social Security (SSA-1945) Bencor Information

Please feel free to contact Sub Central with any questions or concerns you may have regarding the attached documents, or if you need assistance at any time throughout the hiring process.

Email: subcentral@pasco.k12.fl.usTelephone: (813)794-2490 or (813)794-2947

Address: 7227 Land O'Lakes Blvd. Bldg 4, Land O'Lakes, FL 34638Fax: (813)794-2171

To help simplify filling out the forms, please start here:

Enter your full name: ________________________________________

Applicant PIN# or Munis ID# (if known): _____________________

DISTRIBUTION: HREQ; Cost Center

District School Board of Pasco County PERSONAL INFORMATION FORM

Location: __Sub- Central_________________ #: _9013_____

TO BE COMPLETED BY EMPLOYEE:

SOCIAL SECURITY NUMBER DATE OF BIRTH SEX

M F

NAME (Must match name exactly as on Social Security Card) Last Suffix First Middle

ADDRESS (Residence) Street City State Zip Code

ADDRESS (Mailing) If different from aboveStreet City State Zip Code

COUNTRY OF CITIZENSHIP HOME PHONE CELL PHONE

Do you qualify for an exemption under Florida Statutes Sec.119.071 to exclude specific personal information, such as your phone number and home address from disclosure in response to public records requests? Yes No Unknown All employees must also complete the Employee Information Exemption from Public Records Form to officially claim the above-mentioned exemption or indicate that an exemption does not apply.

EMERGENCY CONTACT NAME RELATIONSHIP WORK PHONE HOME PHONE CELL PHONE

DISABILITY/IMPAIRMENT Code Definition: P - Physically Impaired V - Visually Impaired H - Hearing Impaired CODE: _______ S - Speech Impaired O - Other Health Impaired Z - Not Applicable

Were you enrolled in a Florida Retirement System by a previous employer? YES NO

If yes, last day worked

In order to comply with government reporting requirements, the District School Board of Pasco County invites employees to voluntarily and confidentially self-identify their race and ethnicity. Submission of the following information is voluntary and the refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws. When reported, data will not identify any specific individual. Are you Hispanic or Latino? Yes No (“Hispanic or Latino,” is defined to mean a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race.)

RACE (all that apply): White Asian American Indian/Alaskan NativeBlack or African American Native Hawaiian or Other Pacific

MIS Form #304 Rev. 2/15

Substitute Assignment Preference Sheet 

Name:  ______________________________________ 

Please use this as my primary telephone contact number (select one): 

Home # _________________________  Cell # __________________________ 

Please use this as my primary email:  ______________________________________ 

NON‐INSTRUCTIONAL: I would like to be a non‐instructional substitute for any of the following: Custodian  Floater  Food and Nutrition  Instructional Assistant 

Child Care   *Clinic Assistant  *Clerical  Early Head Start Caregiver 

* These positions only available in certain circumstances.

Note: Positions listed may not be available at all schools. The times you can work may not match the hours of the positions that are available at each school. The non‐instructional positions listed in bold letters make up most of the positions available.  

INSTRUCTIONAL:  I would like to be an instructional substitute for any of the following positions:

Adult Education  Agribusiness Natural Res.  American Sign Language  Art  *Autism  Business Education  Commercial Arts  Compliance  Cosmetology  Culinary Arts  Cyesis Program  Dance  Deaf/Hard of Hearing  Diversified Occupations  Drama  Dropout Prevention (Elem) 

Elementary K‐5  Energy  English as a Second Language  *Emotional/Behavioral Disab.  Family Consumer Science  Floater   Foreign Language  *Gifted  Graduation Enhancement  Health  Heating and Air Conditioning  Industrial Education  *Intellectual Disabilities  Language Arts  Leadership Skills  Mathematics 

Music  Physical Education  Physically Impaired  *Pre‐K Varying Excep.  Prekindergarten  Public Service Occupations  Reading  Science  Social Studies  Technology Education  *Therapeutic Pre‐K  *Varying Exceptionalities  *Vision Impaired  Vocational Cosmetology  *Instructional Assistant ESE

*Assignments with an asterisk indicate you would be subbing for teachers of students with exceptional

needs. 

Do you hold an active Florida Teaching Certificate?     Yes      No 

District School Board of Pasco County EMPLOYEE INFORMATION EXEMPTION FROM PUBLIC RECORDS FORM

Employees (with few exceptions) must complete and submit this form to the Office for Human Resources and Educator Quality for the following reasons: 1) to exclude (as exempt under Florida Statutes Sec.119.071) their home address and telephone number and effective October 1, 2012, dates of birth (for most categories) and numbers for home phones, personal cell phones, pagers and personal communication devices (and in many cases, their photograph) from disclosure in response to public records requests (based on their own current/past employment or being the spouse or child of a qualifying person), as well as 2) to exempt certain similar information, as specified in the Statute, from disclosure relating to their spouse and children (including places of employment, names and locations of schools and day care facilities attended by the children). Per Florida Statutes Chapter 119, it is the policy of this State that "every person who has custody of a public record shall permit the record to be inspected and copied by any person desiring to do so....Providing access to public records is a duty of each agency.” Failure to submit this form timely may result in disclosure of certain information, including your home address and telephone numbers (including unlisted/unpublished numbers) and/or photograph, in response to a public records request.

Employee Name Location Location #

To be eligible to claim exemption numbers 11, 13, 14 and 17 below, the person whose position is described in that category must have made reasonable efforts to protect such information from being accessible through other means available to the public.

I DO NOT qualify for any of the exemptions below at this time. ( NOTE: If you, your spouse, your child(ren) or a child residing with you, do qualify for an exemption at some point in the future, notify the Office for Human Resources and Educator Quality by completing and submitting this form. It is the employee's responsibility to notify the Office for Human Resources and Educator Quality in order to ensure that appropriate public records exemptions are applied.) If you do not qualify stop here, sign below and submit this form to the Office for Human Resources and Educator Quality. Yes, I qualify for one of the exemption categories below (specify a category, 1-17, by checking the appropriate items):

____ 1. Firefighter certified under Florida Statutes Sec. 633.35 (including certified Forestry firefighters) ____ 2. Current or former Judge or Justice of the Florida Supreme Court; a district court of appeal; circuit court; or county court ____ 3. Current or former enforcement officer (including correction deputy) ____ 4. Current or former correctional or correctional probation officer ____ 5. Current or former personnel of the Department of Children and Family Services whose duties include the investigation of abuse, neglect,

exploitation, fraud, theft, or other criminal activities ____ 6. Current or former personnel of the Department of Health whose duties are to support the investigation of child abuse or neglect ____ 7. Current or former personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and

enforcement of child support enforcement ____ 8. Current or former code-enforcement officer ____ 9. Current or former federal judge (U.S. Court of Appeals, U.S. district court, or U.S. magistrate judge) ____ 10. Current or former state attorney, assistant state attorney, statewide prosecutor, or assistant statewide prosecutor ____ 11. Current or former federal prosecutor (U.S. attorney or assistant U.S. attorney), judge of the U.S. Courts of Appeal, U.S. district judge, or

U.S. Magistrate ____ 12. Current or former Human Resources/Labor Relations/Employee Relations director, assistant director, manager, or assistant manager,

of any local government agency or water management district, whose duties include(d) hiring and firing employees, labor contract negotiation, administration, or other personnel-related duties

____ 13. General magistrate, special magistrate, judge of compensation claims, administrative law judge of the Division of Administrative Hearings, or child support enforcement hearing officer

____ 14. Current or former guardian ad litem, under Florida Statutes Sec. 39.820 ____ 15. Current or former juvenile probation officer, juvenile probation supervisor, detention superintendent, assistant detention

superintendent, senior juvenile detention officer, juvenile detention officer supervisor, juvenile detention officer, house parent I or II, house parent supervisor, group treatment leader, group treatment leader supervisor, rehabilitation therapist, or social services counselor of the Department of Juvenile Justice

____ 16. Current or former public defenders, assistant public defenders, criminal conflict and civil regional counsel, or assistant criminal conflict and civil regional counsel

____ 17. Current or former investigators or inspectors of the Department of Business and Professional regulation

EXEMPTION based on a I am the person described I am the spouse of the person described. Category 1-17 above: I am the child of a person described A child residing with me is the child of a person described.

Specify the exact position and location of current/former employment qualifying for any exemption(s) claimed above:

Position: ________________________________________________ Location: __________________________________________________

I hereby certify that my answers herein are truthful and accurate; I understand that Florida Statutes Sec. 837.06 makes it a second- degree misdemeanor to knowingly make a false statement in writing with the intent to mislead a public servant in the performance of his/her official duty. For employees who have checked box numbers 11, 13, 14 or 17 above: I (or the person whose position is described in that category) am also certifying that I have made reasonable efforts to protect such information from being accessible through other means available to the public.

Signature of Employee: ___________________________________________________________ Date: _______________________________

Employee ID:

Sub-Central 9013

District School Board of Pasco County ELIGIBILITY FOR GROUP HEALTH INSURANCE

04/2014

Benefits Eligibility

Employees in a benefits-earning position are eligible for group health insurance on the first day of the month following one month of continuous employment. For example, if your date of hire is March 15, you are eligible for coverage on May 1.

It is important that all new benefit eligible employees check their Pasco County School email regularly for time -sensitive communications regarding their benefit enrollment window. Employees should be able to access “Employee Self-Service” (ESS) as benefit enrollment will be completed on-line in Employee Self-Service. Employees who do not make benefit elections by their deadline will be enrolled in the default medical plan, at no cost to the employee.

An Employee who has satisfied the benefit eligibility waiting period is eligible for group health insurance if he or she is actively employed on the effective date of coverage.

Location: Sub Central Last 4 Digits of SSN or Employee ID #:

Employee Name:

NEW APPOINTMENT (NEW HIRE):

Eligible for group health insurance

Not Eligible for group health insurance

Employee’s Signature Required

INCREASE/DECREASE IN HOURS (CURRENT EMPLOYEE):

Employee’s Signature Required

Original to HREQ Copy to Employee Benefits Administration

Eligible for group health insurance

Not Eligible for group health insurance

FORWARD ORIGINAL TO HREQ (EMPLOYEE BENEFITS)

COMPLETE SECTION III OR IV

RETIREE DEFINITION

You are considered retired if:

1. You have receivedany benefits underthe FRS PensionPlan (includingDROP) or

2. You have taken anydistribution(including arollover) from theFRS InvestmentPlan, or alternativeretirementprograms offeredby stateuniversities(SUSORP) or stategovernment forsenior managers(SMSOAP), or localgovernments forsenior managers.

MIS Form #162 Rev. 2/15

Applicant Name SSN Work Location: Sub Central

This form must be used for ALL new or reemployment occurring after July 1, 2010. Any other version of this form is invalid.

PLEASE COMPLETE SECTION(S) I, II, III OR IV I. I have never been a member of a State of Florida administered retirement plan.

SIGNATURE DATE

II. I am a current or previous member of the following State of Florida administered retirement plan.FRS Pension DROP SUSORP OTHER

FRS Investment SCCCOP SMSOAP

III. I am not retired from any State of Florida administered retirement plan. I understand that if it is later determined that I was aretiree and was reemployed during the first 6 calendar months after I retired or after my DROP termination date, or at any timeduring the 7th through 12 months after I retired or after my DROP termination date, I must repay all unauthorized benefitsreceived (see Section IV for details), or, if in the Investment Plan, terminate my employment.

I have contacted the Florida Retirement System and confirmed my retirement status indicated above.

SIGNATURE DATE

IV. I am retired from a State of Florida administered. The effective date of my retirement, conclusion ofDROP, or first distribution from the FRS Investment Plan was .

(You are retired if you are receiving monthly benefits under the FRS Pension Plan or have taken any distributionunder the FRS Investment Plan or optional non-FRS plans (e.g. SCCORP, SUSORPP, or SMSOAP)).

I understand:

a. Pension Plan Retiree or DROP ParticipantIf I am employed by an FRS employer in any type of position (temporary, seasonal, part-time or full-time, or regular position) during the first six calendar months after I retired or ended myparticipation in DROP under a State of Florida administered retirement system, my retirement andDROP status are voided, all retirement and DROP benefits I received must be repaid, and I mustreapply for retirement benefits before my retirement will be effective.

b. Investment Plan RetireeIf I am employed by an FRS employer in any type of position (temporary, seasonal, part-time or full-time or regular position) during the first six calendar months after I take a distribution or withdrawfunds from my FRS Investment Plan account, I must repay any benefits received or terminateemployment.

c. Retiree• If I am reemployed at any time from the seventh through the twelfth month after my retirement

or conclusion of DROP, my monthly retirement benefit must be suspended during months 7 - 12of my retirement.

• If reemployed, I am not eligible for FRS membership (second retirement plan).

SIGNATURE DATE Employees completing Section IV cannot start work before verification of their retirement status. Please sign below attesting that the employee has not started working and that you have forwarded this form to the Employee Benefits Department for verification.

__________________________________________________ ___________________ Signature Date

New Hire/Re-employment Certification - To Be Complete by Employee Benefits Administration

RETIREMENT PLAN: _______________________________________ DATE OF RETIREMENT/DROP OR FIRST DISTRIBUTION: ___________________________ ELIGIBLE FOR EMPLOYMENT NOT ELIGIBLE FOR EMPLOYMENT ELIGIBLE FOR EMPLOYMENT WITHOUT PENALTY AFTER: ________________________

Printed Name Signature Date

Employee Acknowledgement: I acknowledge that I have received a signed copy of this document. ________ (Initial Here)

District School Board of Pasco County NEW HIRE FRS DECLARATION FORM

(Re-Employment after Retirement Declaration)

STOP HERE

PRINCIPALS/DIRECTORS

MIS Form #162 Rev. 5/14

GUIDELINES FOR EMPLOYMENT AFTER RETIREMENT

Florida Retirement System Contact Information Please remember, if you are a retiree of the Pension Plan, a DROP participant or have taken a distribution or withdrawal from your FRS Investment Plan, you should always contact the Florida Retirement System before you are reemployed in any capacity with any FRS employer in your first year of retirement.

Pension Plan and DROP Participants ............................ Bureau of Retirement Calculations ........... (888) 738-2252 Investment Plan Members ........................................... MyFRS Financial Guidance Line................. (866) 446-9377

1. If you are not retired and earned FRS service after certain periods in 2002 (depending on your employer), you must rejoin the FRS retirementplan you were enrolled in when you terminated FRS-covered employment. You may have a one-time 2nd Election to switch FRS retirementplans. Also, non-FRS plans are available to certain State University (i.e. SUSORP), Community College (i.e. CCORP) and State SeniorManagement Class (i.e. SMSOAP) employees.

2. You are retired if you are receiving monthly benefits under the FRS Pension Plan or have taken any distribution under the FRS Investment Plan or optional non-FRS plans (e.g. SCCORP, SUSORPP, or SMSOAP).

3. The School Board may not hire a person within six (6) calendar months of the member receiving a distribution from the FRS Investment Plan.For example, if the distribution date was May 20, the person’s rehire date must be Dec. 1 or later.

4. Any employee, who retires from any State of Florida administered retirement plan must end employment relationships with all FRS employers and remain off all FRS payrolls for at least six calendar months (1st to end of month) following his or her retirement date or DROP terminationdate. If not, the employee’s retirement will be voided and all retirement benefits, including any funds accumulated during DROP participation,must be repaid. For example, if an employee terminates employment September 15, FRS considers the participant to have retired as ofOctober 1; therefore he or she may not return to work with an FRS employer until April 1, or later.

5. Retirement under the FRS Investment Plan may occur at any age after one full year of creditable service and employment with all FRS employers ends. The School Board may not hire an Investment Plan retiree until after he or she has been retired for six calendar months. Forexample, if a participant terminates employment with one full year of creditable service on April 30, and receives his or her first distribution on August 20, FRS considers the participant to have retired as of August 20; therefore he or she may not return to work with an FRS employeruntil the following March 1, or later. Any employee who violates reemployment of the Investment Plan will be required to repay the invalid distribution.

6. After retiring under the Florida Retirement System (FRS) or concluding DROP participation, a retiree may work for any private employer or forany public employer who does not participate in the FRS without affecting his or her FRS retirement benefits. However, retirees including Investment Plan and DROP participants are subject to certain limitations with respect to their employment with any FRS employer during the first twelve (12) months of retirement. There are no limits on working for an FRS employer after you have been retired for 12 months.

7. Reemployed retirees are not eligible for renewed FRS membership (second retirement plan).

8. A disability retiree cannot work in gainful employment and continue to receive disability benefits. Disability retirees must discontinuebenefits upon reemployment.

EARLIEST REHIRE DATE RETIREES ARE ELIGIBLE FOR REEMPLOYMENT ON OR AFTER THE 1ST DAY OF THE MONTH

PENSION OR DROP PARTICIPANT INVESTMENT PLAN PARTICIPANT EFFECTIVE DATE WITH PENALTY WITHOUT PENALTY MONTH OF DISTRIBUTION WITH PENALTY WITHOUT PENALTY

JANUARY JULY JANUARY JANUARY AUGUST JANUARY FEBRUARY AUGUST FEBRUARY FEBRUARY SEPTEMBER FEBRUARY MARCH SEPTEMBER MARCH MARCH OCTOBER MARCH APRIL OCTOBER APRIL APRIL NOVEMBER APRIL MAY NOVEMBER MAY MAY DECEMBER MAY JUNE DECEMBER JUNE JUNE JANUARY JUNE JULY JANUARY JULY JULY FEBRUARY JULY AUGUST FEBRUARY AUGUST AUGUST MARCH AUGUST SEPTEMBER MARCH SEPTEMBER SEPTEMBER APRIL SEPTEMBER OCTOBER APRIL OCTOBER OCTOBER MAY OCTOBER NOVEMBER MAY NOVEMBER NOVEMBER JUNE NOVEMBER DECEMBER JUNE DECEMBER DECEMBER JULY DECEMBER

AUTHORIZATION /AGREEMENT FOR AUTOMATIC DEPOSIT OF PAYROLL

Name:____________________________________ SS#____________________Work Location: Sub-Central

Please read the following important information and instructions to initiate direct deposit of your payroll check to the

financial institution of your choice.

1) Complete this form in its entirety.

2) It is your responsibility to submit correct information. Your deposit will only be as accurate as the informationyou provide.

3) The activation of your direct deposit could take up to six weeks. Once this completed form is received by thePayroll Department, a two step process begins:

a. A pre-note transmission is made to verify the account information.b. After pre-note completion, direct deposit will be activated for the next payroll.

**Please notify the Payroll Department of account closings, bank changes and account changes. Changing banksand/or accounts will require a pre-note transmission. A paper check will be issued while account information isverified. Changes not reported to the Payroll Department may result in delay of payment.**

Financial Institution Name and Address: Check One:_____New Authorization _____Change of Authorization

__________________________________________ Transit/ABA Number:

_______________________________________________________________________________________

Account Number:

__________________________________________ _____________________________________________

Type of Account_______Checking _______Savings

I hereby certify that I am an owner of the above account and authorize the Payroll Department to deposit the full netamount of my payroll check to the financial institution/account indicated above, and to post debit entries to correct anydeposits made in error. This authorization shall remain in full force and effect until you have received written notificationfrom me of its termination in such a manner as to afford you a reasonable opportunity to act upon it.

__________________________________________________ ____________________Employee Signature Date

NOTE: If you do not provide direct deposit information, you will need to pick up your paycheck from the District Office location:

20430 Gator Lane Business Services Center, Bldg 4Land O'Lakes, FL 34638Hours: 8:00-4:00pm

Form W-4 (2015)Purpose. Complete FormW-4 so that your employercan withhold the correct federal income tax from yourpay. Consider completing a new FormW-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 expiresFebruary16, 2016. SeePub. 505, Tax Withholdingand EstimatedTax.Note. If another person can claim you as a dependenton his or her tax return, you cannot claim exemptionfrom withholding if your incomeexceeds $1,050andincludes more than $350 of unearned income (forexample, interest and dividends).Exceptions. An employeemay be able to claim

exemption 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; oritemizeddeductions, 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.Taxcredits.Youcantakeprojectedtaxcreditsintoaccountin figuringyourallowablenumberofwithholdingallowances.CreditsforchildordependentcareexpensesandthechildtaxcreditmaybeclaimedusingthePersonalAllowancesWorksheetbelow.SeePub.505for informationonconvertingyourothercreditsintowithholdingallowances.

Nonwage income. If you havea largeamount ofnonwage income,such as interestor dividends,consider makingestimated tax payments usingForm1040-ES,EstimatedTax for Individuals.Otherwise,youmay owe additional tax. If you havepensionor annuityincome,seePub. 505 to find out if you should adjustyour withholding on FormW-4 or W-4P.Two earners or multiple jobs. If you haveaworking 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 FormW-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 FormW-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).Futuredevelopments.InformationaboutanyfuturedevelopmentsaffectingFomnW-4(suchaslegislationenactedafterwereleaseit)willbepostedatwww.irs.gov/w4.

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

I ·You are single and have only one job; or IBEnter "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.CEnter "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

FEnter "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.)

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 ($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,CXXland $84,000($100,000and $119,000 if rnarried), enter "1" for each eligible child. GH 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.) ... H

For accuracy, 1complete allworksheetsthat apply.

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductionsand Adjustments Worksheet on page 2.

• If you are single and have more than one job or are married and you and your spouse both work and the combinedearnings from all jobs exceed $50,000 ($20,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 toavoid 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. ------.----------- .. - ------

W-4 Employee's Withholding Allowance Certificate OMB No. 1545-0074Form ~(Q)15Departmentof theTreasury ... Whether you are entitled to claim a certain number of allowances or exemption from withholding isInternal RevenueService 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

ILast name

12Your social security number

Home address (number and street or rural route) 3D Single 0 Married 0 Married, but withhold at higher Single rate.Note. Ifmarried,butlegallyseparated,or spouseisa nonresidentalien,checkthe"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 1·800·772·1213for a replacement card. "'0

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 56 Additional amount, if any, you want withheld from each paycheck 6 $7 I claim exemption from withholding for 2015, 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 . ' ...t,7....s- '" fIf you meet both conditions, write "Exempt" here. ... I 7 I

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.) ~ Date ~

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

Cat. No. 102200 FormW-4 (2015)For Privacy Act and Paperwork Reduction Act Notice, see page 2.

Form W-4 (2015) Page 2Deductions 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 2015itemized 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);$284,050if you are head of household; $258,250if you are single and nothead of household or a qualifying widow(er);or $154,950if you are married filing separately.See Pub. 505for details 1 $

I $12,600 if married filing jointly or qualifying widow(er) )2 Enter: $9,250 if head of household 2 $$6,300 if single or married filing separately

3 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 toWithholding Allowances for 2015 Form W-4 worksheet in Pub. 505.) . 5 $

6 Enter an estimate of your 2015 nonwage income (such as dividends or interest) 6 $

7 Subtract line 6 from line 5. If zero or less, enter "-0-" 7 $

8 Divide the amount on line 7 by $4,000 and enter the result here. Drop any fraction 89 Enter the number from the Personal Allowances Worksheet, line H, page 1 9

10 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 10

Two-Earners/Multiple Jobs Worksheet (SeeTwo earners ormultiole jobs on oaqe 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 10above if you used the Deductions and Adjustments Worksheet) 12 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 morethan "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 tofigure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet 45 Enter the number from line 1 of this worksheet 56 Subtract line 5 from line 4 . 67 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 twoweeks 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 Married Filing Jointly All Others

If wagesfromLOWEST Enter on If wagesfrom LOWEST Enter on If wages from HIGHEST Enter on If wages from HIGHEST Enter onpayingjob are- line 2 above payingjob are- line 2 above paying job are- line 7 above paying job are- line 7 above

$0 - $6,000 0 $0 - $8,000 0 $0 - $75,000 $600 $0 - $38,000 $6006,001 13,000 1 8,001 - 17,000 1 75,001 - 135,000 1,000 38,001 - 83,000 1,00013,001 24,000 2 17,001 - 26,000 2 135,001 - 205,000 1,120 83,001 - 180,000 1,12024,001 26,000 3 26,001 34,000 3 205,001 - 360,000 1,320 180,001 - 395,000 1,32026,001 34,000 4 34,001 44,000 4 360,001 - 405,000 1,400 395,001 and over 1,58034,001 44,000 5 44,001 75,000 5 405,001 and over 1,58044,001 50,000 6 75,001 85,000 650,001 - 65,000 7 85,001 110,000 765,001 75,000 8 110,001 125,000 875,001 80,000 9 125,001 140,000 980,001 100,000 10 140,001 and over 10

100,001 115,000 11115,001 130,000 12130,001 140,000 13140,001 150,000 14150,001 and over 15

PrivacyAct andPaperworkReductionAct Notice,Weaskfor the informationon thisformto carryout the InternalRevenuelawsof theUnitedStates.InternalRevenueCodesections3402(D(2)and6109andtheir regulationsrequireyouto providethis information;youremployerusesit to determineyourfederalincometaxwithholding.Failureto provideaproperlycompletedformwill resultin yourbeingtreatedasasinglepersonwhoclaimsnowithholdingallowances;providingfraudulentinformationmaysubjectyouto penalties.Routineusesof this informationincludegivingit to theDepartmentof Justicefor civilandcriminallitigation;to cities,states,the Districtof Columbia,andU.S.commonwealthsandpossessionsfor useinadministeringtheirtax laws;andto theDepartmentof HealthandHumanServicesfor usein theNationalDirectoryof NewHires.Wemayalsodisclosethis informationto othercountriesundera tax treaty,to federalandstateagenciesto enforcefederalnontaxcriminallaws,or to federallawenforcementandintelligenceagenciesto combatterrorism.

Youarenot requiredto providethe informationrequestedona formthat issubjectto thePaperworkReductionAct unlesstheformdisplaysa validOM8 controlnumber.Booksorrecordsrelatingto a formor its instructionsmustbe retainedas longastheircontentsmaybecomematerialin the administrationof anyIntemalRevenuelaw.Generally,tax returnsandreturninformationareconfidential,as requiredbyCodesection6103.Theaveragetimeandexpensesrequiredto completeandfilethis formwillvarydepending

on individualcircumstances.Forestimatedaverages,seethe instructionsfor yourincometaxreturn.

Ifyouhavesuggestionsformakingthis formsimpler,wewouldbehappyto hearfromyou.Seethe instructionsfor yourincometax return.

District School Board of Pasco County CONFIDENTIALITY AGREEMENT

Employee ID: ___________________ Name: _____________________________________

Department/Location: ____Sub-Central____________

For individuals accessing information from confidential student records maintained by

Pasco County Schools

I acknowledge that school or district staff have advised me of the Florida statutes and district School Board policies/ procedures regarding the protection and confidentiality of student records.

I understand that student record information is confidential regardless of the form in which it is maintained and/or shared (verbal, conferences, observations, documents in a cumulative student record folder, electronic information, etc.).

I agree to access and share information contained in student records only as a part of my official work assignment and only for legitimate educational purposes.

I will maintain complete confidentiality on all information received and will not release information to a third party.

This agreement applies to paid and unpaid staff, volunteers, practicum and intern students.

____________________________________________ ___________________________ Employee Signature Date

DISTRICT SCHOOL BOARD OF PASCO COUNTY

ELECTRONIC NETWORK USE GUIDELINES FOR EMPLOYEES

Employee use of any of the network resources (i.e., computers, electronic mail, conferences, bulletin boards, databases, and access to the Internet), referred to as "the network", are to be used in a responsible, efficient, ethical, and legal manner. Any employee working with students who are utilizing the network has the responsibility to monitor such use to assure compliance with the Electronic Network Use Guidelines for Students. The following guidelines have been established for all employee use of the network. Failure to follow these guidelines may result in the loss of access to the network or other disciplinary action.

Acceptable Uses of the Network • all activities which support the mission, vision, and curriculum of the District School Board of Pasco County• all activities which are related to employee job functions

Unacceptable Uses of the Network Unacceptable uses include, but are not limited to: • using or communicating with others who are using impolite, abusive, or objectionable language.• using the network in ways that violate federal, state, or local laws.• using the network in ways that violate School Board Policies or district procedures.• activities which cause congestion of the network or otherwise interfere with the work of others.• using the network for commercial or financial gain.• using the network for non-school related and non-approved advertising or solicitation.• sending or receiving copyrighted materials without permission.• modifying data, programs, or other information on computer networks without the consent of the owner(s).• using the network for sending, retrieving, or viewing obscene materials.• circumventing security and/or authentication measures.• unauthorized access to anotherʼs resources, programs, or data.• vandalizing network resources, including the uploading or creation of computer viruses.• falsifying oneʼs identity to others while using the network.• installation of unauthorized software on the computer networks.• use of network resources to commit forgery, or to create a forged instrument.• representing personal views as those of the District School Board of Pasco County.

Classroom Accounts • Sponsors of classroom accounts are responsible for teaching proper techniques and standards for accessing and using the network.• Supervision of student use of network resources is the responsibility of the teacher or other supervising adult allowing student access.

Students must be informed of both acceptable and unacceptable uses of the network.

Conference Moderators • Conference moderators are responsible for monitoring the content of posted messages.

Network Management • Appropriate use of the network is the responsibility of the user. Monitoring of network use is the responsibility of each site supervisor.

Individuals involved in maintaining the network infrastructure do not have the responsibility for preventing harm caused directly or indirectlyby inappropriate use of the network.

Public Information • Electronic communications should never be considered private. The District School Board of Pasco County is subject to Florida Statutes

regarding public information access. As such, most electronic messages or network transmissions are a matter of public record. It is theresponsibility of each person to retain electronic communications according to Florida Records Retention Policies.

Student and Employee Information • Confidential information concerning students or employees must be safeguarded from unauthorized access. It is the responsibility of each

user to take appropriate steps to ensure that confidentiality of data is maintained through all network activities. All applicable laws andpolicies against sexual harassment and discrimination apply to electronic communication the same as any other form of communication.

Passwords • Passwords are designed to prevent unauthorized access to information. They are not to be construed as a method of providing personal

privacy of data. Users are responsible for safeguarding passwords and are accountable for negligent disclosure of passwords.

Privacy • Employees shall have no expectation of privacy while using the network. All stored data, electronic messages, and electronic

transmissions may be monitored. Employees should be aware that electronic communications and files may exist in backup form in otherlocations on the district network. Employees should not assume that they have a right to privacy with regard to data created, received,used, or stored with district computer equipment or transmitted through the district network.

Signature Print Name Employee ID# Date

Failure to sign this agreement does not relieve the employee from complying with the guidelines. DISTRIBUTION: White - Human

Resources; Canary - Cost Center; Pink - Employee

MIS Form #190 Rev. 2/15

TOGETHER WESTAND

BULLYING IS EVERYONE'S PROBLEM

As per Pasco County School District policy, any student who believes he /she has been or is the victim of bullying or harassment should report the incident(s) to the principal or designee as soon as possible after the alleged incident .. The student may also report concerns to teachers or counselor who will be responsible for notifying the principal or designee.

All school employees are required to report alleged violations of this policy to the principal or as described above. All other members of the school cominunity, including students, parents, volunteers, and visitors, are encouraged to report any act that may be a violation of this policy to the principal or as described above.

Written and oral reports shall be considered official reports. Reports may be made anonymously, but formal disciplinary action may not be based solely on the basis of an anonymous report.

The Pasco County School District website and each school website has a direct link to anonymously report bullying.

Signature Date

TOGETHER WE STAND

BULLYING IS EVERYONE'S PROBLEM_______________________________________________________________________

As per Pasco County School District policy, any student whobelieves he /she has been or is the victim of bullying orharassment should report the incident(s) to the principal ordesignee as soon as possible after the alleged incident. Thestudent may also report concerns to teachers or counselor whowill be responsible for notifying the principal or designee.

All school employees are required to report alleged violations ofthis policy to the principal or as described above. All othermembers of the school cominunity, including students, parents,volunteers, and visitors, are encouraged to report any act thatmay be a violation of this policy to the principal or as describedabove.

Written and oral reports shall be considered official reports.Reports may be made anonymously, but formal disciplinaryaction may not be based solely on the basis of an anonymousreport.

The Pasco County School District website and each schoolwebsite has a direct link to anonymously report bullying.

____________________________ ______________Signature Date

District School Board of Pasco County SCHOOL BOARD POLICY ACKNOWLEDGEMENT

The District School Board of Pasco County believes that a safe, secure, nurturing, and civil environment is essential in accomplishing its educational mission. This philosophy of inclusion and respect is clearly articulated in the following District School Board Policies:

The Nondiscrimination and Equal Employment Opportunity Policy (1122, 3122, 4122) states that, “[t]he District School Board of Pasco County does not discriminate on the basis of race, color, sex/gender, religion, national origin, marital status, disability, genetic information or age in its educational programs, services or activities, or in its hiring and employment practices.” If a person believes that s/he has been discriminated against or harassed because of one of these protected classes, the District has developed a complaint process (1122.04, 3122.04, 4122.04) to provide prompt, fair investigation and equitable resolution.

As articulated in the Respect and Civility Policy, the District promotes mutual respect, civility and orderly conduct among all employees, students, parents, and the general public. This Policy (1380, 3380, 4380) is intended to maintain, to the extent that is possible and reasonable, a safe, harassment-free workplace that is free of disruptive demeaning, intimidating, threatening, or aggressive behavior. Staff are expected to treat students, parents, fellow staff members and members of the public with respect and expect the same in return. Volatile, hostile, or aggressive actions and words will not be tolerated and employees who engage in these actions may face disciplinary action.

The Equity Manager, Sandy May, is available to provide assistance or additional information on the above-referenced board policies at smay@pasco.k12.fl.us or 813-794-2579.

In addition to the above, every school district employee is bound to comply with all School Board policies as a condition of their employment. The policies referenced in this notice along with all School Board policies can be accessed at http://www.neola.com/pasco-fl/. All employees are encouraged to be familiar with those that are applicable to their responsibilities.

Do you understand the School Board Policies regarding non-discrimination and workplace civility?

YES NO

Do you understand that, as an employee of the DSBPC, you have an obligation to comply with School Board Policy, including those regarding non-discrimination and workplace civility?

YES NO

Employee Signature: ___________________________________ Date: ________________________

Employee Name: _________________________________ Employee ID: ___________

Location: Sub-central

District School Board of Pasco County LOYALTY OATH

(Required by Section 876.05, Florida Statutes)

I, ____________________________________________ , a citizen of the State of Florida and

of the United States of America, and being employed by or an officer of the District School

Board of Pasco County, Florida, and a recipient of public funds as such employee or officer, do

hereby solemnly swear or affirm that I will support the Constitution of the United States and of

the State of Florida.

_____________________________________ Signature

Revised 1/2017

__________________________

Date

FORWARD ORIGINAL TO HREQ (CLAIMS ADMINISTRATION) PROVIDE A COPY TO EMPLOYEE Rev. 04/2014

District School Board of Pasco County WORKERS’ COMPENSATION ACKNOWLEDGEMENT OF PROCEDURES

Office for Human Resources and Educator Quality Workers’ Compensation 813/ 794-2520 FAX: 813/ 794-2039 727/ 774-2520 TDD: 813/ 794-2484 352/ 524-2520

Johns Eastern Company (JECO) has been chosen as the District School Board of Pasco County’s (the District) workers’ compensation administrator. As the administrator, JECO will coordinate all claim and medical services for your work-related injury.

If your work-related accident results in the need for medical treatment, you will be sent to the nearest Health and Wellness Center (HWC) in the District’s authorized workers’ compensation provider network (WC provider network). In coordination with Johns Eastern Medical Management Services Department, the HWC is responsible for managing your medical care, including referrals to other health care providers and facilities for evaluation or treatment. Johns Eastern Medical Management Services Department must approve ALL referrals for treatment or evaluation before you receive services.

Your Rights and Responsibilities

You have certain rights and responsibilities entitled to you under the District’s workers’ compensation program. This information is detailed in the online “Employee Handbook for Workers’ Compensation” . We urge you to immediately read the handbook and refer to it if you experience a work-related injury. Additionally, workers’ compensation procedures and a list of authorized providers are available at your worksite and online at http://www.pasco.k12.fl.us/benefits/comp/. If you do not have access to download the Employee Handbook for Workers’ Compensation” you may email mybenefits@pasco.k12.fl.us to request a copy.

Notice of Emergency Treatment If you are involved in a work-related accident that is serious and requires immediate treatment, go to the nearest urgent care facility, hospital emergency room or call 911. After receiving treatment at a hospital emergency room, you are required to follow-up with one of the CareHere Health and Wellness Centers for evaluation and a release to return to work. If the accident occurred after hours and you sought medical treatment, you must report the injury by 8:30 a.m. the next business day.

“First Aid or Report Only” Notice If you are involved in a work-related accident and elect NOT to seek medical treatment at time of accident, you MUST immediately notify Johns Eastern Company at 1-800-749-3044 extension 1322 should you decide to seek medical treatment in the future. In addition, you must inform the Workers’ Compensation Designee at your work location that you have decided to seek medical treatment.

Return-to-Work (RTW) Program The Return-to-Work (RTW) Program promotes your successful return to work as quickly as medically possible, bringing you back to work when you are able to perform on a modified or alternate duty basis. Your participation in the RTW Program is required when you are offered modified or alternate duties within the functional limitations and restrictions identified by your authorized treating provider. Refusal to participate in the RTW Program may negatively impact your workers’ compensation benefits, as well as possible discipline up to and including termination from the District.

Fraud Statement Workers’ compensation fraud occurs when any person knowingly, and with intent to injure, defraud, or deceive, any employer or employee, insurance company, or self-insured program, files false or misleading information. Workers’ compensation fraud is a third degree felony that can result in fines, civil liability, and jail time.

I acknowledge that I have read and understand the above statements about Workers’ Compensation.

Employee Name (PLEASE PRINT) Employee ID Number

Employee Signature Date Signed

Employee Worksite Employee Name (Please print)

Employee Social Security Number Employee Personal Phone Number

Pasco’s Ethical Standards

Overview

Acknowledgement Form

I acknowledge that I have:

1. viewed Pasco County’s Ethical Standards video presentation.

2. received a copy of “The Code of Ethics and the Principles ofProfessional Conduct of the Education Profession in Florida”.

In addition, I have been provided the opportunity to ask questions about this information and been informed of resources for additional information.

Principal or Worksite Supervisor Employee Signature Date

Completed forms are to be sent to the Office for Human Resources and Educator Quality.

SubCentral

ER 509 0916

Pasco County Schools

REASONABLE SUSPICION DRUG TESTING PROGRAM ACKNOWLEDGMENT FORM

Name: _____________________________________ Employee ID: ___________________

Location: ___________________________________

Information for employees about Pasco’s Reasonable Suspicion Drug Testing Program

I acknowledge that I:

1) Have been provided instruction to access the District’s “Drug and Alcohol Awareness”manual posted online.

2) Understand that the “Drug and Alcohol Awareness” manual contains information foremployees covered by the program, including standards of conduct related to drugs andalcohol and consequences for a violation of the program’s provisions.

3) Understand that district employees are subject to the Reasonable Suspicion DrugTesting Program and that employees who engage in prohibited drug/alcohol relatedconduct, as verified by the testing results, must be immediately removed from duty.

4) Understand that I may obtain assistance or additional information by contacting theProgram Manager at the Office for Employee Relations, 813-794-2322.

____________________________________________ ___________________________ Employee Signature Date

____________________________________________ ___________________________ Principal or Worksite Supervisor Signature Date

Completed forms are to be sent to the Office for Human Resources and Educator Quality

SubCentral

District School Board of Pasco County

MANDATORY REPORTING OF CHILD ABUSE AND NEGLECT ACKNOWLEDGMENT FORM

I have completed the coursework required for Mandatory Reporting of Child Abuse and Neglect for my position type as follows:

Instructional: I have completed the Department of Children and Families' one hour course Identifying and Reporting Child Abuse and Neglect. A copy of the certificate of completion must be returned to the Office for Human Resources & Educator Quality. You may view the podcast at: http://www3.fl-dcf.org/RCAAN/

Non-Instructional:

I

Procedures podcast and information posted on the Office for Employee Relations and understand the expectations for employees as mandatory reporters. You may view the podcast at: http://www.pasco.k12.fl.us/er/child_abuse_podcast

1.

2. I understand that I am required to report and cooperate with authorized lawenforcement agencies and the Department of Children and Families and comply withinvestigations relating to child abuse, abandonment, and neglect, or an allegedunlawful sexual offense involving a child.

Additional resources are available at:http://www.pasco.k12.fl.us/library/er/reporting_child_abuse.pdf

____________________________________________ ___________________________ Employee Signature Date

Completed forms are to be sent to the Office for Human Resources and Educator Quality

I understand that I may obtain assistance or additional information bycontacting Elizabeth Kuhn at ekuhn@pasco.k12.fl.us or David Chamberlin atdachambe@pasco.k12.fl.us

3.

DISTRICT SCHOOL BOARD OF PASCO COUNTY NOTICE OF SOCIAL SECURITY NUMBER DISCLOSURE

Section 119.071(5)(a)2.-4., Florida Statutes requires agencies to notify individuals of the purpose(s) that require the collection of Social Security numbers. The District School Board of Pasco County collects social security numbers (SSNs) for the following purposes:

• The Internal Revenue Service and Social Security Administration require a Social Securitynumber on a Form W-4, that is used to determine how much federal withholding tax is to becollected and Federal Insurance Contribution Act (FICA) tax on wages paid and later reported ina W-2 Wage and Tax Statement.

• The Internal Revenue Service requires a Taxpayer Identification Number on Form W-9 whichcould be a Social Security or an Employer Identification number that could be used to generate a1099 Miscellaneous Income Statement based on expenditures processed through accountspayable. Vendors with Social Security numbers are captured in the Vendor Application process.

• The Human Resources/Finance software program requires use of Social Security numbers as theprimary personal identification of employees for wages, leaves, payroll deductions, etc.

• Social Security numbers are also used as identifiers for processing fingerprints with the FederalBureau of Investigation and the Florida Department of Law Enforcement.

• Social Security numbers are requested by the National School Lunch Act from parents on the freeor reduced price meal application and household verification process as part of determining afamily’s eligibility for their child(ren) for free or reduced price meals.

• Social Security numbers for employees and dependents are required for enrollment in healthinsurance, life insurance, and other miscellaneous insurances.

• Social Security numbers are used by the Florida Department of Education as a standardizedidentification number for the required reporting of yearly certification and training information.

• Social Security numbers are required by the Florida Division of Retirement to report earningsused to document creditable years of service in the Florida Retirement System.

• The District telephone system requires the use of employee Social Security numbers to track longdistance calls and to allow access for substitutes to use the “sub dialer”.

• Social Security numbers are used by the Florida Department of Education as a standardizedidentification number to track students from year to year and when they move from one school orcounty to another.

• Social Security numbers are used for students in grades 10 through 12 as identifiers for collegesand scholarship programs such as Bright Futures. For students in grades Pre-Kindergartenthrough 12, Social Security numbers are used as identifiers for enrollment and attendance,funding reports (such as FTE), tracking of achievement gains, and standardized testing such asFCAT. Student Social Security numbers are included in all Florida Department of Educationrequired reporting.

• For adult students and approved GED Exit Option students taking the GED exam for graduationpurposes, social security numbers are used by the Florida Department of Education as astandardized identification number to track students.

The Social Security numbers of all current and former employees are confidential and exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.

Statement Concerning Your Employment in a JobNot Covered by Social Security

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 figured using 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 offset 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 Security 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)

Employee Name Employee ID#

Employer Name Employer ID#Pasco County Schools 59-6000792

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:

• 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. Therequest must include the name, complete address and telephone number of the employer. Forms will not be sent toa 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)

INFORMATION ABOUT YOUR BENCOR PLAN During May & June 2013 BENCOR, Inc. launched a new web experience for Participants and Plan Sponsors. We’ve also upgraded our recordkeeping platform for more enhanced services. Please review the following information:

Features of the Participant Web site Unit Values

Account Balance

Account Balance, by Fund

Fund Transfers

On Line Beneficiary Designation

Transaction History

Enrollment Materials / Process

Download Forms

Investment Fund Objectives

Performance Information

Address Changes

Investment Allocation Changes

Special Pay Loans:

o Outstanding Loan Balance

o Amount Available for Loan

o Modeling, Initiation, and Payoff

New Website: We have been listening to your requests and are pleased to announce an enhanced Website which includes the following features:

Logging into Website: You’ll continue to access the website at www.bencorplans.com. Click on the Participant Logon link to access the new features. When logging in for the first time, you will need to establish a new Customer ID & Password. Here are the 5 quick steps:

1. Select If you’re new to this site, Welcome option2. Click Get Started box3. Complete Create Your Customer ID Section

[Note: you may choose an Identification Number other than your SSN for your ID]

4. Complete Create Your Password Section5. Hit Next to continue and access your account information

1 Bencor, Inc.

Password Reset In the event you forget your password, the password hint will be sent to the e-mail address on file. If you do not have an e-mail address on file, a customer service representative can assist you.

Naming Your Beneficiary You may now enter and update your beneficiary designations online. Allow a few hours after you complete the online designation for your beneficiary information to be viewable online. This information will also be shown on your quarterly or annual statements.

If you previously submitted a paper beneficiary form, it will not be available on the new website. As part of your financial planning, it’s a good idea to periodically review your beneficiary designations. Please take this opportunity to update your beneficiary designations to ensure that your wishes are properly documented for your heirs. If you prefer to use a paper form, you may download the current form to do so.

Distribution Processing Distributions are processed within 1 – 3 business days of receipt of a distribution request in good order which meets all plan provisions, including any applicable wait period. Funds are then sent the following business day.

Funds may be distributed via check, wire, or ACH. You may elect the method of payment on the distribution form. Overnight delivery is available for a $25 fee, which will be deducted from your account.

Special Pay Loan Repayments Special Pay participants who elect a plan loan will receive coupons for repayment processing. Electronic loan repayments via ACH debit from your bank account can be established on-line.

2 Bencor, Inc.

Participation in Multiple Plans If you participate in both a FICA Alternative and a Special Pay Plan, you will receive separate statements for each account. Your Special Pay account statement will be sent quarterly; your FICA Alternative statement will be sent annually. They will no longer be combined.

E-Services You can choose E-documents to help eliminate paper. E-documents is a secure, fast and free service. Log into the website, enter an email address and then subscribe for e-documents. You can then access and print e-docs as needed from your computer or other devices.

E-Documents include Statements, Prospectuses and Confirmations.

Availability of Account Information: Website: www.bencorplans.com

Automated Voice Response: (888) 258-3422; 24 hours per day, 7 days a week; Account Information & Transaction Initiation.

BENCOR Customer Service Representatives: (888) 258-3422; Available Monday – Friday 8:30 a.m. – 5:00 p.m. ET.

3 Bencor, Inc.