NEW HIRE PACKET

Infiniti HR3905 National Dr. Ste. 400Burtonsville, MD 20866

301-841-6380Toll Free 866-552-6360Fax: 240-722-0090

www.infinitihr.com

vJan2019

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Welcome  to  INFINITI  HR.  Your  Employer  has  contracted  with  INFINITI HR  to  provide  you  with  some  of  the  most  comprehensive  and  flexible  Payroll,  Human  Resource,  Employee  Benefits  and  Risk  Management  services.  Our  goal   is   to  make  your  employer’s  job  easier  and  to  provide  you  with  extensive  employee  benefit  options.  

At   INFINITI HR   we   have   several   different   service   models,   so   you   may   hear   terms   like  Professional   Employer  Organization  (PEO)  or  Administrative  Service  Organization  (ASO).  

The   PEO  model   establishes   a   co-­‐employment   relationship   with   your   present   employer   that   divides  the   duties   of   the   employer   into   “On-­‐site   Employer”,   and   “Professional   Employer.”   This   relationship  allows   you   to   become   part   of   a   larger   group   so   that   you   can   access   additional   resources   and  benefits,  while  providing  administrative  relief  to  your  current  employer.  

The  ASO  model  allows  INFINITI HR  to  become  your  off-site  Human  Resources  Department  under  a  more  traditional  service  provider  relationship.  

We  hope  that  you  will  be  as  excited  as  we  are  that  your  current  employer  has  decided  to  partner   with  INFINITI HR.  If  you  have  any  questions  you  can  always  call  us  at  our  toll  free  number  listed  below.  

1.866.552.6360 www.infinitihr.com

INSTRUCTIONS:  

Page  2  3  4  5  

6  8  9  

12  16  

Employee  Enrollment  Check  List  Complete  Employee  Data  Form  EEO-1  Voluntary Self-Identification  Form:  Read  and  then  complete  requested  information.   Direct  Deposit  Authorization:  Complete  if  you  want  your  paycheck  deposited  directly   into   your  account(s).  Attach  voided  check(s)  for  checking  account(s).  Contact  your  bank  for  the  necessary  form  for  direct  deposit  to  a  savings  account.  Employment  Policies:  Read  and  keep  for  your  records.  Acknowledgment  Form:  Sign  and  return  to  INFINITI HR.  Form  I-9:  Complete  and  sign  Employment  Eligibility  Verification  form.  Employers  must  complete  and  sign  Form  I-9  Section  2.  For  a  full  copy  of  the  I9,  containing  all  instructions,  please  go  to  http://www.uscis.gov/i9  or  call  1-800-375-5283.  Form  W-4:  Employee’s  Withholding  Allowance  Certificate.Complete  and  sign.  Form 8850 and Work Opportunity Tax Credit Questionnaire (WOTC): Pre-Screening Notice and Certification Request. Complete, sign and return the original to INFINITI HR.

3905 National Drive, Suite 400, Burtonsville, MD 20866 I 301-841-6380 I 240-722-0090 (F)

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Employee Enrollment Check List

Enclosed  is  the  documentation  required  to  transition  your  personnel  file  to  INFINITI HR and  process  your  paycheck.  

! Employment  Application/Employee  Data  Form

! EEO-1  Voluntary Self-Identification  Form

! Direct  Deposit  Authorization

! Employment  Policies

! Acknowledgment  Form

! Form  I-­‐9,  Employment  Eligibility  Verification

! Form  W-­‐4,  Employee’s  Federal  Withholding  Allowance  Certificate

! Applicable  State  Tax  Withholding  Form.  Your  Federal  withholding  allowance  will  beused if a state withholding form is not returned.

The completed forms must be received by INFINITI HR no later than 2 days after the first day worked to ensure the employee will receive a payroll check on the next regularly scheduled payday.

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Employee Data Form

Social  Security  Number:    Employee ID:

Employee  Name:    Last   First    Middle  

Date  of  Birth:        Email:  

Address:    

House/Street   City/State/Zip  

(     )                    (     )        Home  Telephone  Number              Cell  Telephone  Number  

Emergency  Contact  

Name:     Telephone:  

Address:    

Relationship  to  Employee:  

Finally,  I  certify  all  information  provided  by  me  is  true  and  correct  and  understand   that  any  intentional  falsification  of  information  is  grounds  for  termination.  

Signature  of  Applicant   Date

TO  BE  COMPLETED  BY  THE  CLIENTClient  Name:    Hire  Date:  

Job  Title:   Pay  Rate:  $  _________      per    ____________  

EMPLOYEE  TYPE:  

Part-Time

Full-Time

Hourly  

Salary  

Commission Only Department: ______________________________________

Division: __________________________________________

EEO-1 Voluntary Self-Identification Form

It is the policy of INFINITI HR to provide equal employment and advancement opportunities to all individuals.

The following information is used to assist INFINITI HR in maintaining the statistics for the annual EEO-1 Report which we are required to submit to the Federal Government each year. Completion of this form is voluntary and in no way affects any decision regarding your employment.

This form is confidential and will be maintained separately from your application.

Name: Date:

Position Title:

GENDER (Please check one of the options) MALE FEMALE

RACE/ETHNICITY (Please check one of descriptions below corresponding to the ethnic group with which you identify)

HISPANIC OR LATINO: a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American,

or other Spanish culture or origin, regardless of race.

WHITE: a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

BLACK OR AFRICAN AMERICAN: a person having origins in any of the black racial groups of Africa.

ASIAN: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the

Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,

the Philippine Islands, Thailand, and Vietnam.

NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER: a person having origins in any of the original peoples

of Hawaii, Guam, Samoa, or other Pacific Islands.

AMERICAN INDIAN OR ALASKA NATIVE: a person having origins in any of the original peoples of North

and South America (including Central America), and who maintains tribal affiliation or community

attachment.

TWO OR MORE RACES: a person who primarily identifies with two or more of the above race/ethnicity

categories.

I DO NOT WISH TO DISCLOSE

4INFINITI HR - CONFIDENTIAL

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Direct Deposit Form

Company  Name:    

Employee  Name:    

I  authorize  INFINITI  HR,  Cachet  Banq  and  all  financial  institution(s)  involved  in  each  transaction  to  deposit  my  pay  automatically  to  the  indicated  account(s)  and  to  make  adjusting  entries  including  the  removal  of  funds  if  the  employer  does  not  make  them  available,  in  which  case,   I  waive  any  rights  I  may  have  to  return  debit  entries  to   my  account  and  personally  guaranty   the  return  of  the  funds  in  question.  

BANK  /  CREDIT  UNION   STATE   TYPE   AMOUNT   ACCOUNT  NUMBER  (Circle  One)  

o Checking

o Saving

o Checkingo Saving

o Checking

o Saving

Please  Check  One:

New  or  Additional  Direct  Deposit  

Change  the  Bank  or  Account  Number  on  an  Existing  Direct  Deposit  Account  

Number  to  Be  Replaced:    

Change  the  amount  of  an  existing  Direct  Deposit  Amount  was:       Amount  Changed  to:  

Other  (Please  Explain):  

Please  Attach  a  Voided  Check  for  the  Direct  Deposit  Bank  Account  as  Verification  for  Each  Request.  

Deposits   are   normally   available   two   (2)   banking   days   after   payroll   is   processed.   It   is   my   responsibility   to  verify  deposits  on  a  per  pay  period  basis  before  writing  checks  against  these   funds.  This  Authorization  can  take   up   to   three   (3)   pay   periods   to   activate.   I   understand   that   neither   Infiniti   HR   or   Cachet   Banq   is   responsible   for   bank   errors   or   bank   fees.   Direct   Deposit   Financial   services   are   provided   in   accordance   with  INFINITI HR’s   Direct   Deposit   Agreement,   Cachet   Banq’s   Power   of   Attorney/Guaranty/Terms   and   Conditions   and   the   limitations   and   restrictions   of   the   National   Automated   Clearing   House   Association.   I  may   cancel  these  Direct   Deposit(s)  at  any  time.  

Signature   Date  

Routing Number  

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Employment Policies

DRUG  AND  ALCOHOL  FREE  WORKPLACE  POLICY  INFINITI HR   and   our   clients   strive   to   provide   a   safe   work   environment   and   encourage   personal   health.   In   keeping   with  this  policy,  the  company  considers  the  abuse  of  drugs  or  alcohol  on  the  job  to  be  an  unsafe   and  a  counter   productive   work   practice.   It   is,   therefore,   company   policy   that   an   employee   detected   to   have   alcohol   or   illegal  drugs   in   his/her  system,  in  possession  of,  using,  selling,  trading,  or  offering  for  sale  illegal   drugs  or  alcohol  during  working   hours,  will  be   subject  to  disciplinary  action  including  discharge.  (Company  sponsored  activities  which  may  include  the  service  of  alcoholic  beverages  are  not  included  in  this  provision.  Discretion  should  be  exercised  by  the  employee  to  avoid  overindulging  in  the  consumption   of   alcohol.)   Substance   Abuse   includes   possession,   use,   purchase,   or   sale   of   drugs   or   alcohol   on   company   premises  (including  the  parking  lots).  

Employees  will  be  required  to  submit  to  drug  and/or  alcohol  testing  at  a  laboratory  chosen  by  the  company  for  the  following  reasons:  

1. Observed  alcohol  or  drug  abuse  during  work  hours  on  company  premises.

2. Apparent  physical  state  of  impairment.

3. Incoherent  mental  state.

4. Accidents  or  other  actions  that  provide  reasonable  cause  to  believe  the  employee  may  be  underthe  influence.

5. As  required  by  any  government  programs  such  as  the  US  Department  of  Transportation.

In   addition   to   testing   for   the   purposes   above,   Infiniti   HR   and   its   clients   reserve   the   right   to   randomly   test   employees.   Refusal   to   such   testing   will   subject   an   employee   to   disciplinary   action   up   to   and   including   termination   of  employment.  

ANTI-HARRASSMENT

INFINITI HR and its client companies have zero tolerance for and therefore prohibit all forms of discriminatory practices, including unlawful harassment of employees by managers, fellow employees, and employees of contractors, visitors or any other third parties on Infiniti HR or client company premises. This prohibition includes but is not limited to any demeaning, insulting, embarrassing or intimidating behavior directed at any employee because of their race, color, religion, sex, age, sexual orientation, national origin, genetic information, disability or any other protected characteristic as established by law.

Sexual harassment constitutes discrimination and is illegal under Federal, state and local laws. For the purposes of this policy, sexual harassment is defined, as in the Equal Employment Opportunity Commission Guidelines, as unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexual nature when, for example: (i) submission to such conduct is made either explicitly or implicitly a term or condition of an individual's employment; (ii) submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual; or (iii) such conduct has the purpose or effect of unreasonably interfering with an individual's work performance or creating an intimidating, hostile or offensive working environment.

Sexual harassment can take two distinct forms: quid pro quo and hostile work environment. One, quid pro quo harassment, occurs when submission to sexual conduct is made a condition of employment or employment benefits. Two, hostile work environment occurs when sexual or other discriminating and unlawful conduct unreasonably interferes with an employee’s work performance or creates an intimidating, abusive, or offensive work environmen

Harassing conduct that is PROHIBITED includes, but is not limited to epithets, slurs or negative stereotyping, threatening, intimidating or hostile acts, denigrating jokes and display or circulation in the workplace of written or graphic material that denigrates or shows hostility or aversion toward an individual or group (including through e-mail).

Incidents of alleged discrimination or harassment will be taken seriously by the client Company. Infiniti HR offers an HR Hotline for reporting and will assist with or guide a client company on how to investigate and proceed with corrective action if necessary.

Retaliation Is ProhibitedINFINITI HR and its client companies prohibit retaliation against any individual who reports discrimination or harassment or participates in an investigation of such reports. Retaliation against an individual for reporting harassment or discrimination or for participating in an investigation of a claim of harassment or discrimination is a serious violation of this policy and, like harassment or discrimination itself, will be subject to corrective action.

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REPORTING  PROCEDURE  Any individual who believes they have witnessed or been subject to discrimination, including unlawful harassment, regardless of the offender's identity or position, must report the circumstances as soon as possible to any one of the following: immediate Supervisor or Manager, authorized internal or INFINITI HR assigned Human Resources Administrator, Officer of the Company or similar high level Executive, or any person designated in the Employee Handbook as a Contact Person. Upon completion of any investigation, Infiniti HR or the client company will take appropriate action.

ADA  and  ADAA  POLICYINFINITI HR and client companies are committed to complying with all applicable provisions of the Americans with Disabilities Act (ADA) and the Americans with Disabilities Act Amendments Act (ADAAA). It is the policy of Infiniti HR and Client Company to not discriminate against any qualified employee with regard to any terms or conditions of employment because of the individual’s disability or perceived disability so long as the qualified individual can perform the essential functions of the job.

Client Company will provide reasonable accommodations to a qualified individual with a disability so that they canperform the essential functions of a job unless doing creates an undue hardship to the client company.

This policy is neither exhaustive nor exclusive. Infiniti HR and Client Company is committed to taking all other actions necessary to ensure equal employment opportunity for persons with disabilities in accordance with the ADA, ADAAA and all other applicable federal, state, and local laws.

REQUESTING  AN  ACCOMODATION  If an employee feels that are in need of an accommodations, they should contact their immediate Supervisor or Manager, authorized internal or Infiniti HR assigned Human Resources Administrator, Officer of the Company or similar high level Executive, or any person designated in the Employee Handbook as a Contact Person.

PAYROLL  DEDUCTIONS  The  following  mandatory  deductions  will  be  made  from  every  employee’s  gross  wages:  federal  income  tax,   Social  Security  FICA  tax,  and  applicable  city  and  state  taxes.  

Every  employee  must  fill  out  and  sign  a  federal  withholding  allowance  certificate,  IRS  Form  W-­‐4,  on  or  before  his  or  her  first  day  on  the  job.  This  form  must  be  completed  in  accordance  with  federal  regulations.  

The  employee  may  fill  out  a  new  W-­‐4  at  any  time  when  his  or  her  circumstances  change.  Employees  who   paid  no  federal  income  tax  for  the  preceding  year  and  who  expect  to  pay  no  income  tax  for  the  current  year  may  fill  out  an  Exemption  from  Withholding  Certificate,  IRS  Form  W-­‐4E.  Employees  are  expected  to  comply  with  the  instructions  on  Form   W-­‐4.   Questions   regarding   the   propriety   of   claimed   deductions   may   be   referred   to   the   IRS   in   certain  circumstances.  

Other  optional  deductions  include  the  portion  of  group  health  insurance  not  paid  by  the  company,  which  is   deducted  from  each  payroll  check.  Other  voluntary  contributions,  such  as  credit  union  and  pension  plan,  are  also  deducted  each  pay  period.  Any  other  deductions  from  pay  require  your  voluntary,  written  and  specific   authorization  to  do  so.  

INFINITI HR and Client Company will follow any state or local law that provides individuals with disabilities greater protection than the ADA & ADAAA.

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ACKNOWLEDGEMENT

I acknowledge that I have received my copy of the INFINITI HR Employment Policies, contained within its New Hire Packet used by worksite employer.

I have read and understand these policies and acknowledge that they outline practices, expectations and guidelines set by INFINITI HR , agreed to by my worksite employer, that I am required to follow. I further understand that violations of the policies contained within, including but not limited to the anti-harassment policy, could result in corrective action, up to and including termination.

Since the information in these policies is subject to change as situations warrant, it is understood that changes in future new hire packets or policies within similar HR documents, such as my worksite employer’s Employee Handbook, may supersede, revise, or eliminate one or more of the policies. These changes will be identified or communicated to me by my supervisor/manager or through similarly responsible worksite representatives. I accept responsibility for keeping informed of these changes.

I further acknowledge my understanding that my employment with INFINITI HR is considered at will and may be terminated at any time with or without cause. Only official executed, legally binding contracts of employment supersede employment at will

Employee’s  Signature:    Date:  

Name  (Please  Print):      

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 07/17/17 N Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically,during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

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

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

Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee's E-mail Address Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.I attest, under penalty of perjury, that I am (check one of the following boxes):

1. A citizen of the United States

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

3. A lawful permanent resident

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

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

(Alien Registration Number/USCIS Number):

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

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

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

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

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

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

Employer Completes Next Page

Form I-9 07/17/17 N Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 08/31/2019

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number

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

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

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

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

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

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

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

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

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

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

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

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

LIST A

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

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

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

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

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

Documents that Establish Both Identity and

Employment Authorization

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

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

and(2) An endorsement of the alien's

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

a. Foreign passport; and

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

listed above:

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

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

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

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

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

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

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

4. Native American tribal document

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

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 07/17/17 N

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form W-4 (2019)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2019 if both of the following apply.• For 2018 you had a right to a refund of all federal income tax withheld because you had no tax liability, and

• For 2019 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2019 expires February 17, 2020. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General Instructions

If you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2019 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

You can also use the calculator at www.irs.gov/W4App to determine your tax withholding more accurately. Consider

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income not subject to withholding outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2019. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married filing jointly and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income not subject to withholding, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Additional Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific Instructions

Personal Allowances Worksheet

Complete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you may claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.

Line E. Child tax credit. When you file your tax return, you may be eligible to claim a child tax credit for each of your eligible children. To qualify, the child must be under age 17 as of December 31, must be your dependent who lives with you for more than half the year, and must have a valid social security number. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line F. Credit for other dependents. When you file your tax return, you may be eligible to claim a credit for other dependents for whom a child tax credit can’t be claimed, such as a qualifying child who doesn’t meet the age or social security number requirement for the child tax credit, or a qualifying relative. To learn more about this credit, see Pub. 972. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total

Separate here and give Form W-4 to your employer. Keep the worksheet(s) for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee’s Withholding Allowance Certificate Whether you’re entitled to claim a certain number of allowances or exemption from withholding is

subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.

OMB No. 1545-0074

20191 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

3 Single Married Married, but withhold at higher Single rate.

Note: If married filing separately, check “Married, but withhold at higher Single rate.”

4 If your last name differs from that shown on your social security card,

check here. You must call 800-772-1213 for a replacement card.

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . . 5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2019, and I certify that I meet both of the following conditions for exemption.

• Last year I had a right to a refund of all federal income tax withheld because I had no tax liability, and

• This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.If you meet both conditions, write “Exempt” here . . . . . . . . . . . . . . . 7

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

Employee’s signature

(This form is not valid unless you sign it.) Date

8 Employer’s name and address (Employer: Complete boxes 8 and 10 if sending to IRS and complete boxes 8, 9, and 10 if sending to State Directory of New Hires.)

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2019)

Form W-4 (2019) Page 2

income includes all of your wages and other income, including income earned by a spouse if you are filing a joint return.Line G. Other credits. You may be able to reduce the tax withheld from your paycheck if you expect to claim other tax credits, such as tax credits for education (see Pub. 970). If you do so, your paycheck will be larger, but the amount of any refund that you receive when you file your tax return will be smaller. Follow the instructions for Worksheet 1-6 in Pub. 505 if you want to reduce your withholding to take these credits into account. Enter “-0-” on lines E and F if you use Worksheet 1-6.

Deductions, Adjustments, and Additional Income Worksheet

Complete this worksheet to determine if you’re able to reduce the tax withheld from your paycheck to account for your itemized deductions and other adjustments to income, such as IRA contributions. If you do so, your refund at the end of the year will be smaller, but your paycheck will be larger. You’re not required to complete this worksheet or reduce your withholding if you don’t wish to do so.

You can also use this worksheet to figure out how much to increase the tax withheld from your paycheck if you have a large amount of nonwage income not subject to withholding, such as interest or dividends.

Another option is to take these items into account and make your withholding more accurate by using the calculator at www.irs.gov/W4App. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Two-Earners/Multiple Jobs Worksheet

Complete this worksheet if you have more than one job at a time or are married filing jointly and have a working spouse. If you

don’t complete this worksheet, you might have too little tax withheld. If so, you will owe tax when you file your tax return and might be subject to a penalty.

Figure the total number of allowances you’re entitled to claim and any additional amount of tax to withhold on all jobs using worksheets from only one Form W-4. Claim all allowances on the W-4 that you or your spouse file for the highest paying job in your family and claim zero allowances on Forms W-4 filed for all other jobs. For example, if you earn $60,000 per year and your spouse earns $20,000, you should complete the worksheets to determine what to enter on lines 5 and 6 of your Form W-4, and your spouse should enter zero (“-0-”) on lines 5 and 6 of his or her Form W-4. See Pub. 505 for details.

Another option is to use the calculator at www.irs.gov/W4App to make your withholding more accurate.Tip: If you have a working spouse and your incomes are similar, you can check the “Married, but withhold at higher Single rate” box instead of using this worksheet. If you choose this option, then each spouse should fill out the Personal Allowances Worksheet and check the “Married, but withhold at higher Single rate” box on Form W-4, but only one spouse should claim any allowances for credits or fill out the Deductions, Adjustments, and Additional Income Worksheet.

Instructions for Employer

Employees, do not complete box 8, 9, or 10. Your employer will complete these boxes if necessary.

New hire reporting. Employers are required by law to report new employees to a designated State Directory of New Hires. Employers may use Form W-4, boxes 8, 9,

and 10 to comply with the new hire reporting requirement for a newly hired employee. A newly hired employee is an employee who hasn’t previously been employed by the employer, or who was previously employed by the employer but has been separated from such prior employment for at least 60 consecutive days. Employers should contact the appropriate State Directory of New Hires to find out how to submit a copy of the completed Form W-4. For information and links to each designated State Directory of New Hires (including for U.S. territories), go to www.acf.hhs.gov/css/employers.

If an employer is sending a copy of Form W-4 to a designated State Directory of New Hires to comply with the new hire reporting requirement for a newly hired employee, complete boxes 8, 9, and 10 as follows. Box 8. Enter the employer’s name and address. If the employer is sending a copy of this form to a State Directory of New Hires, enter the address where child support agencies should send income withholding orders. Box 9. If the employer is sending a copy of this form to a State Directory of New Hires, enter the employee’s first date of employment, which is the date services for payment were first performed by the employee. If the employer rehired the employee after the employee had been separated from the employer’s service for at least 60 days, enter the rehire date.Box 10. Enter the employer’s employer identification number (EIN).

Form W-4 (2019) Page 3

Personal Allowances Worksheet (Keep for your records.)A Enter “1” for yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A

B Enter “1” if you will file as married filing jointly . . . . . . . . . . . . . . . . . . . . . . . B

C Enter “1” if you will file as head of household . . . . . . . . . . . . . . . . . . . . . . . C

D Enter “1” if: { • You’re single, or married filing separately, and have only one job; or• You’re married filing jointly, have only one job, and your spouse doesn’t work; or• Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.

} D

E Child tax credit. See Pub. 972, Child Tax Credit, for more information.• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “4” for each eligible child. • If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “2” for each eligible child.

• If your total income will be from $179,051 to $200,000 ($345,851 to $400,000 if married filing jointly), enter “1” for each eligible child.

• If your total income will be higher than $200,000 ($400,000 if married filing jointly), enter “-0-” . . . . . . . E

F Credit for other dependents. See Pub. 972, Child Tax Credit, for more information.• If your total income will be less than $71,201 ($103,351 if married filing jointly), enter “1” for each eligible dependent.

• If your total income will be from $71,201 to $179,050 ($103,351 to $345,850 if married filing jointly), enter “1” for every two dependents (for example, “-0-” for one dependent, “1” if you have two or three dependents, and “2” if you have four dependents).

• If your total income will be higher than $179,050 ($345,850 if married filing jointly), enter “-0-” . . . . . . . F

G Other credits. If you have other credits, see Worksheet 1-6 of Pub. 505 and enter the amount from that worksheet here. If you use Worksheet 1-6, enter “-0-” on lines E and F . . . . . . . . . . . . . . . . . . G

H Add lines A through G and enter the total here . . . . . . . . . . . . . . . . . . . . . . H

For accuracy, complete all worksheets that apply. {

• If you plan to itemize or claim adjustments to income and want to reduce your withholding, or if you have a large amount of nonwage income not subject to withholding and want to increase your withholding, see the Deductions, Adjustments, and Additional Income Worksheet below.

• If you have more than one job at a time or are married filing jointly and you and your spouse both work, and the combined earnings from all jobs exceed $53,000 ($24,450 if married filing jointly), see the Two-Earners/Multiple Jobs Worksheet on page 4 to 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 above.

Deductions, Adjustments, and Additional Income Worksheet

Note: Use this worksheet only if you plan to itemize deductions, claim certain adjustments to income, or have a large amount of nonwage income not subject to withholding.

1

Enter an estimate of your 2019 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 10% of your income. See Pub. 505 for details . . . . . . . . . . . . . . . . . . . . . . 1 $

2 Enter: { $24,400 if you’re married filing jointly or qualifying widow(er)$18,350 if you’re head of household$12,200 if you’re single or married filing separately

} . . . . . . . . . . . 2 $

3 Subtract line 2 from line 1. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . . 3 $4 Enter an estimate of your 2019 adjustments to income, qualified business income deduction, and any

additional standard deduction for age or blindness (see Pub. 505 for information about these items) . . 4 $5 Add lines 3 and 4 and enter the total . . . . . . . . . . . . . . . . . . . . . . 5 $6 Enter an estimate of your 2019 nonwage income not subject to withholding (such as dividends or interest) . 6 $7 Subtract line 6 from line 5. If zero, enter “-0-”. If less than zero, enter the amount in parentheses . . . 7 $8 Divide the amount on line 7 by $4,200 and enter the result here. If a negative amount, enter in parentheses.

Drop any fraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, above . . . . . . . . . . 9

10

Add lines 8 and 9 and enter the total here. If zero or less, enter “-0-”. If you plan to use the Two-Earners/

Multiple Jobs Worksheet, also enter this total on line 1 of that worksheet on page 4. Otherwise, stop here

and enter this total on Form W-4, line 5, page 1 . . . . . . . . . . . . . . . . . . . 10

Form W-4 (2019) Page 4

Two-Earners/Multiple Jobs Worksheet

Note: Use this worksheet only if the instructions under line H from the Personal Allowances Worksheet direct you here.

1

Enter the number from the Personal Allowances Worksheet, line H, page 3 (or, if you used the Deductions, Adjustments, and Additional Income Worksheet on page 3, the number from line 10 of that worksheet) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

2

Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you’re married filing jointly and wages from the highest paying job are $75,000 or less and the combined wages for you and your spouse are $107,000 or less, don’t enter more than “3” . . . . . . . . . . . . . 2

3 If line 1 is more than or equal to line 2, subtract line 2 from line 1. Enter the result here (if zero, enter “-0-”) and on Form W-4, line 5, page 1. Do not use the rest of this worksheet . . . . . . . . . . . . 3

Note: If line 1 is less than line 2, enter “-0-” on Form W-4, line 5, page 1. Complete lines 4 through 9 below to figure the additional withholding amount necessary to avoid a year-end tax bill.

4 Enter the number from line 2 of this worksheet . . . . . . . . . . . 4

5 Enter the number from line 1 of this worksheet . . . . . . . . . . . 5

6 Subtract line 5 from line 4 . . . . . . . . . . . . . . . . . . . . . . . . . . 6

7 Find the amount in Table 2 below that applies to the HIGHEST paying job and enter it here . . . . . 7 $8 Multiply line 7 by line 6 and enter the result here. This is the additional annual withholding needed . . . 8 $

9

Divide line 8 by the number of pay periods remaining in 2019. For example, divide by 18 if you’re paid every 2 weeks and you complete this form on a date in late April when there are 18 pay periods remaining in 2019. Enter the result here and on Form W-4, line 6, page 1. This is the additional amount to be withheld from each paycheck . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 $

Table 1

Married Filing Jointly

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $5,000 05,001 - 9,500 19,501 - 19,500 2

19,501 - 35,000 335,001 - 40,000 440,001 - 46,000 546,001 - 55,000 655,001 - 60,000 760,001 - 70,000 870,001 - 75,000 975,001 - 85,000 1085,001 - 95,000 1195,001 - 125,000 12

125,001 - 155,000 13155,001 - 165,000 14165,001 - 175,000 15175,001 - 180,000 16180,001 - 195,000 17195,001 - 205,000 18205,001 and over 19

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $7,000 07,001 - 13,000 1

13,001 - 27,500 227,501 - 32,000 332,001 - 40,000 440,001 - 60,000 560,001 - 75,000 675,001 - 85,000 785,001 - 95,000 895,001 - 100,000 9

100,001 - 110,000 10110,001 - 115,000 11115,001 - 125,000 12125,001 - 135,000 13135,001 - 145,000 14145,001 - 160,000 15160,001 - 180,000 16180,001 and over 17

Table 2

Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $24,900 $42024,901 - 84,450 50084,451 - 173,900 910

173,901 - 326,950 1,000326,951 - 413,700 1,330413,701 - 617,850 1,450617,851 and over 1,540

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $7,200 $4207,201 - 36,975 500

36,976 - 81,700 91081,701 - 158,225 1,000

158,226 - 201,600 1,330201,601 - 507,800 1,450507,801 and over 1,540

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person who claims no withholding allowances; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to

cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You aren’t required to provide the information requested on a form that’s subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating

to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

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

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

Form 8850(Rev. March 2016)

Department of the Treasury Internal Revenue Service

Pre-Screening Notice and Certification Request for the Work Opportunity Credit

▶ Information about Form 8850 and its separate instructions is at www.irs.gov/form8850.

OMB No. 1545-1500

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name Social security number ▶

Street address where you live

City or town, state, and ZIP code

County Telephone number

If you are under age 40, enter your date of birth (month, day, year)

1 Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agencyfor the work opportunity credit.

2 Check here if any of the following statements apply to you.• I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9

months during the past 18 months.• I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food

stamps) for at least a 3-month period during the past 15 months.

• I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.

• I am at least age 18 but not age 40 or older and I am a member of a family that:a. Received SNAP benefits (food stamps) for the past 6 months; orb. Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.

• During the past year, I was convicted of a felony or released from prison for a felony.• I received supplemental security income (SSI) benefits for any month ending during the past 60 days.• I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the

past year.

3 Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.

4 Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.

5 Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.

6 Check here if you are a member of a family that:• Received TANF payments for at least the past 18 months; or• Received TANF payments for any 18 months beginning after August 5, 1997, and the earliest 18-month period beginning

after August 5, 1997, ended during the past 2 years; or• Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time

those payments could be made.

7 Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that periodyou received unemployment compensation.

Signature—All Applicants Must SignUnder penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.

Job applicant’s signature ▶ Date

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 22851L Form 8850 (Rev. 3-2016)

Have you worked for this Employer before? Are you a Re-hire? Yes_____ No_____ If Yes, enter last day of employment: ______________________

Are you under age 40? Yes_____ No_____

Have you been unemployed for at least 27 weeks, and collected Unemployment Insurance? Yes_____ No_____

Are you a Veteran of the US Armed Forces? Yes_____ No_____ If yes:

Are you a member of a family that received SNAP (Food Stamps Benefits)? Yes_____ No_____ Are you entitled to compensation for a service-connected disability? Yes_____ No_____ Were you discharged from active duty within the last year? Yes_____ No_____ Were you unemployed for a combined total of 6 months before you were hired? Yes_____ No_____

Have you, or your family, received SNAP benefits (Food Stamps) in the 6 months before you were hired? Yes_____ No_____ Or received SNAP Benefits for at least a 3 month period, but you are no longer receiving it? Yes_____ No_____ If yes to either question, enter Name of Primary Recipient: ____________________________________ And City, State where benefits were received_______________________________________________.

Are you a member of a family that received TANF assistance for at least 18 months before you were hired? Yes_____ No_____ Or, did your family stop being eligible for TANF assistance within 2 years before being hired, because you reached the maximum time those benefits can be received? Yes_____ No_____ If yes to either question, enter Name of Primary Recipient: ____________________________________ And City, State where benefits were received_______________________________________________.

Did you receive Supplemental Security Income (SSI Benefits) for any month, ending within the 60 days, before you were hired? Yes_____ No_____

Were you convicted of a Felony during the year before you were hired? Yes_____ No_____

Were you referred to an employer by:

A Vocational Rehab Agency approved by the state? Yes_____ No_____

An Employment Network under the Ticket to Work Program? Yes_____ No_____

The Dept. of Veteran Affairs? Yes_____ No_____

Print Name: _____________________________________

Social Security #: ___________-________-_____________

Date of Birth: ___________________________

This company participates in various federal and state tax credit programs. This information in no way will

negatively impact any hiring, retention decision. Your responses to the questions will only be shared with your

employer’s management and federal, state, or local governmental agencies as needed in administration of these

programs. By completing this form, you knowingly and voluntarily waive any objection to providing your social

security number. Any information provided will be used in a manner consistent with the American Disability Act.

Under penalty of perjury, I certify that this information is true and correct to the best of my knowledge. I hereby

authorize this company’s management, and federal, state, and local government agencies to provide information

to TC Services USA, Inc., and/or SWA, to determine eligibility. I understand that the information above may be

subject to verification.

Employment Start Date_______________ Starting Wage____________ Position___________________

Signature_________________________________________ Today’s Date_________________________

Please fill in these forms slowly and legibly. Company Name: _______________________________________

(no script) Rev. 2/25/16 Company Code for Online Users: __________________

Phone: 212-994-2714 Fax: 212-994-2718 Email: support@tcservicesusa.com

Infiniti HR

PAYROLL HR B ENEFITS

Infiniti HR3905 National Drive, Suite 400 Burtonsville, MD 20866

301-841-6380Toll Free 866-552-6360Fax: 240-722-0090

www.infinitihr.com

(Fold) (Fold) (Fold) (Fold)

How to Claim State Plan Benefi ts1. Use SDI Online to securely fi le for benefi ts or

to request a paper claim form.• By Internet: www.edd.ca.gov/disability.• By phone: 1-800-480-3287.• By TTY (teletypewriter for deaf, hearing-

impaired, and speech-impaired persons only)at: 1-800-563-2441 for DI or 1-800-445-1312for PFL.

• By mail: EDD, Disability Insurance, PO Box13140, Sacramento, CA 95813-3140.

• In person by visiting any of the DI offi ces listedunder “DI Offi ce Locations.”

• California State government employeescovered by SDI should call 1-866-352-7675.

2. When fi ling SDI Online, complete allrequired fi elds. A receipt number will begenerated when your claim is submitted.If using a paper claim form, complete andsign the “Claim Statement of Employee.” Printclearly, and verify your answers are completeand correct as errors delay payments.

3. Have your physician/practitioner completethe “Physician/Practitioner Certifi cation”online or use the paper claim form. If fi lingonline, your physician/practitioner willneed your receipt number to complete the“Physician/Practitioner Certifi cation.”Usually a claim cannot begin more thanseven days before you were examined by orunder the care of a physician/practitioner.Certifi cation may be made by a licensedmedical or osteopathic physician andsurgeon, nurse practitioner, chiropractor,dentist, podiatrist, optometrist, designatedpsychologist, or an authorized medicaloffi cer of a United States Government facility.Certifi cation may also be made by a licensednurse-midwife or licensed midwife fordisabilities related to normal pregnancy orchildbirth.

4. File online or submit your paper claim formwithin 49 days from the fi rst day you weredisabled. If your claim is late, you may losebenefi ts unless your explanation of the delayis accepted as reasonable.

The EDD is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Requests for services, aids, and/or alternate formats need to be made by calling DI at 1-800-480-3287 (voice), or TTY 1-800-563-2441, or PFL at 1-877-238-4373 or TTY 1-800-445-1312.

This pamphlet is for general information only, and does not have the force and effect of the law,

rule or regulation.

Disability is an illness or injury, either physical or mental, which prevents customary work. Disability includes elective surgery, pregnancy, childbirth, or related medical conditions.

Disability Insurance (DI) is a component of the State Disability Insurance (SDI) program, designed to partially replace wages lost due to a non-work-related disability (see “Other Programs,” for job-related disabilities.)

SDI contributions are paid by California workers covered by the SDI program. Contribution rates may vary from year to year. For current rates, visit the DI website at www.edd.ca.gov/disability, or contact the Employment Development Department (EDD) Disability Insurance Customer Service at 1-800-480-3287 or EDD Employment Tax Customer Service at 1-888-745-3886.

DI Plans

• State Plan. DI’s state plan is covered in thisbrochure.

• Voluntary Plan (VP). A private plan, approvedby the Director of EDD, which may besubstituted for the State Plan. Voluntary plansmay be established if the employer andmajority of employees agree to do so. VPinformation and fi ling a claim may be donethrough your employer. If you are covered bya VP, the provisions of the brochure may notapply to you. Obtain information about yourcoverage and fi le a VP claim through youremployer.

• Elective Coverage (EC). Employers and self-employed persons, including general partners,may elect coverage. The method of computingbenefi ts for EC participants is not the sameas for mandatory rate payers. The cost ofparticipating, which is set annually, can beobtained from your local EDD Employment TaxCustomer Service Offi ce.

EC claims are fi led in the same manner asState Plan claims; however, there are somedifferences in eligibility requirements fromthose listed in this pamphlet.

• For additional information or to apply forcoverage, contact EDD DI Customer Serviceat 1-800-480-3287, EDD Employment TaxCustomer Service at 1-888-745-3886, or visitour website at www.edd.ca.gov/disability.

DISABILITYINSURANCE PROVISIONS

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DI Offi ce Locations

Chico ..................................... 645 Salem Street(write to: PO Box 8190, Chico, CA 95927-8190)

Chino Hills .. 15315 Fairfi eld Ranch Road, Ste. 100(write to: PO Box 60006, City of Industry, CA 91716-0006)

Fresno ........... 2550 Mariposa Mall, Rm. 1080A(write to: PO Box 32, Fresno, CA 93707-0032)

Long Beach ... 4300 Long Beach Blvd., Ste. 600(write to: PO Box 469, Long Beach, CA 90801-0469)

Los Angeles ......888 S. Figueroa Street, Ste. 200(write to: PO Box 513096, Los Angeles, CA 90051-1096)

Oakland ............................7677 Oakport Street(write to: PO Box 1857, Oakland, CA 94606-1857)

San Bernardino ...................371 West 3rd Street(write to: PO Box 781, San Bernardino, CA 92402-0781)

San Diego .. 9246 Lightwave Avenue, Bldg. A, Ste. 300(write to: PO Box 120831, San Diego, CA 92112-0831)

San Francisco ....... 745 Franklin Street, Rm. 300(write to: PO Box 193534, San Francisco, CA 94119-3534)

San Jose ..................... 297 West Hedding Street(write to: PO Box 637, San Jose, CA 95106-0637)

Santa Ana . 605 West Santa Ana Blvd., Bldg. 28, Rm. 735(write to: PO Box 1466, Santa Ana, CA 92702-1466)

Santa Barbara ................. 128 East Ortega Street(write to: PO Box 1529, Santa Barbara, CA 93102-1529)

Santa Rosa ................... 606 Healdsburg Avenue(write to: PO Box 700, Santa Rosa, CA 95402-0700)

Stockton ................... 528 North Madison Street(write to: PO Box 201006, Stockton, CA 95201-9006)

California State Government Employees(write to: PO Box 2168, Stockton, CA 95201-2168)

Van Nuys ...........15400 Sherman Way, Rm. 500(write to: PO Box 10402, Van Nuys, CA 91410-0402)

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How Benefi ts Are Paid

• The SDI program serves you electronically or by mail. You do not need to appear in person to apply or receive benefi ts.

• Benefi ts are paid via the EDD Debit CardSM. The EDD Debit CardSM works like other debit cards with access to funds 24 hours a day, 7 days a week and can be used everywhere Visa debit cards are accepted. When your claim is received, you may be contacted through SDI Online, by phone, or by mail for additional information. Most properly completed claims are processed within 14 days.

• The fi rst seven days of your DI claim are a non-payable waiting period.

Benefi ts are paid as quickly as possible after all information to determine eligibility is received. If you meet all eligibility requirements, benefi ts will be authorized. If you are eligible for further benefi ts, you will be sent additional benefi ts electronically or sent a “continued claim” certifi cation form for you to complete for the next benefi t period. Usually these benefi t periods will be in two week intervals. However, DI pays benefi ts based on daily eligibility within a seven-day calendar week. Partial weeks are paid at a daily rate. This rate is one-seventh of your weekly benefi t amount. Please allow 10 days from the date you mail a certifi cation for receipt of payment.How Your Benefi t Rate is DeterminedBenefi t amounts are based on wages paid during a specifi c 12-month base period, determined by the date your claim begins. Consider when to start your claim since this may affect your weekly benefi t rate, your maximum benefi t amount, and the period of your benefi t eligibility.Only base period wages subject to the SDI contributions can be used in computing your benefi ts. To qualify, you must have earned at least $300 during your base period. The month your claim begins determines which four consecutive quarters are used.If your claim begins in:• January, February, or March, your base

period is the 12 months ending last September 30. (Example: A claim beginning

February 14, 2014, uses a base period of October 1, 2012, through September 30, 2013.)

• April, May, or June, your base period is the 12 months ending last December 31.(Example: A claim beginning June 20, 2014, uses a base period of January 1, 2013, through December 31, 2013.)

• July, August, or September, your base period is the 12 months ending last March 31.

(Example: A claim beginning September 27, 2014, uses a base period of April 1, 2013, through March 31, 2014.)

• October, November, or December, your base period is the 12 months ending last June 30. (Example: A claim beginning November 2, 2014, uses a base period of July 1, 2013, through June 30, 2014.)

Exceptions: If your claim is determined to be invalid, but you were unemployed and seeking work for 60 days or more in any quarter of your base period, you may be able to substitute wages paid in prior quarters.

You may be entitled to substitute wages paid in prior quarters to either validate your claim or increase your benefi t amount, if during your base period you:

• were in the military service.

• received Workers’ Compensation benefi ts.

• did not work because of a labor dispute.

If your situation fi ts any of the above, include a note with your claim form.

Wage Continuation. If your employer continues to pay you wages while you are disabled, your DI benefi ts may be affected. DI benefi ts plus wages cannot exceed your regular weekly wage. DI benefi ts are not affected by vacation pay you may receive.

Maximum Benefi ts. The maximum benefi t amount is 52 times the weekly rate, but not more than your total base period wages. Exception: For employers and self-employed individuals who elect SDI coverage, the maximum benefi t amount is 39 times the weekly rate.

Additionally, benefi ts are payable only for a limited period to a resident in an alcoholic

recovery home or drug-free residential facility that is both licensed and certifi ed by the state in which the facility is located. However, disabilities related to or caused by acute or chronic alcoholism or drug abuse, being medically treated, do not have this limitation.

Pregnancy. As with any medical condition, your disability period begins the fi rst day you are unable to do your regular or customary work. DI benefi ts are based on the period of time your physician/practitioner certifi es you are unable to do your regular or customary work. Do not send in your claim for pregnancy-related DI benefi ts until the date your physician/practitioner certifi es you are disabled.

NOTE: For information on Paid Family Leave (PFL) bonding benefi ts, see the “Other Programs” section of this brochure.

You May Not be Eligible for Benefi ts

• If you are receiving UnemploymentInsurance or PFL benefi ts.

• If you are not working or looking for work at the time you become disabled.

• If you are in custody due to conviction of a crime.

• If your full wages are paid.

• If you are receiving Workers’ Compensation at a weekly rate equal to or greater than the DI rate. If Workers’ Compensation benefi ts are paid at a lower rate than your DI rate, you may be paid the difference.

• For the amount of time a claim is late (without good cause).

• If you make a false statement or fail to report a material fact. (A 30 percent penalty may be assessed if benefi ts are overpaid because you willfully withheld a material fact or made a false statement.)

• If you fail to attend an independent medical examination when requested. (Fees for such examinations are paid by the EDD.)

The California Unemployment Insurance Code provides for penalties consisting of fi nes, imprisonment, and loss of benefi t rights for fraud against the SDI program.

Your Rights. You are entitled to:

• Know the reason and basis for any decision that affects your benefi ts.

• Appeal any decision about your eligibility for benefi ts. (Appeals must be sent to the DI offi ce in writing.)

• Request an appeal hearing before an Administrative Law Judge (ALJ). You may further appeal the ALJ’s decision to the California Unemployment Insurance Appeals Board and the courts.

• Privacy – all claim information will be kept confi dential except for the purposes allowed by law.

Your Obligations. Your responsibilities:

• Complete your claim and other forms correctly, completely, and truthfully.

• Submit your claim and other forms according to time limits on forms. If your claim is submitted late and you believe you have a good reason for being late, you should include a written explanation of the reason(s) with the form.

• Contact DI if you do not understand a question or how to answer it.

• Include your name and Social Security number on letters to DI.

Contact DI

• By e-mail at https://ask.edd.ca.gov

• By phone at: 1-800-480-3287 (English) or1-866-658-8846 (Spanish).

• By U.S. mail addressed to PO Box 13140, Sacramento, CA 95813-3140. If you do not have a current claim, you may write to any DI Offi ce.

• By TTY (teletypewriter for deaf, hearing-impaired, and speech-impaired persons only) at 1-800-563-2441.

• In person by visiting any of the DI offi ces listed under “DI Offi ce Locations.”

Other Programs

If you are injured on the job or become ill as a result of your occupation, notify your employer.

If you are able and available to work but unemployed, contact the Unemployment Insurance program of the EDD through the website at www.edd.ca.gov/unemployment, or by phone at 1-800-300-5616 (TTY 1-800-815-9387).

If you need help in fi nding work, job training, retraining, or other services in order to return to work, visit your local America’s Job Center of CaliforniaSM formerly known as One-Stop Career Centers listed through the website at www.servicelocator.org, or in the white pages of your phone directory.

If your disability is permanent or is expected to continue for a year or more, contact the U.S. Social Security Administration through the website at www.ssa.gov, or by phone at 1-800-772-1213 (TTY 1-800-325-0778).

If you take time off work to care for a family member or if you take time off from work to bond with a new child, including newly adopted, newly placed foster children, or those of your registered domestic partner, contact the EDD’s PFL through the website at www.edd.ca.gov/disability, or by phone at 1-877-238-4373 (TTY 1-800-445-1312).

For questions relating to DI, contact the EDD through the website at www.edd.ca.gov/disability, or by phone at 1-800-480-3287 (TTY 1-800-563-2441).

Note: A PFL bonding claim form will be sent automatically with the fi nal benefi t payment to new mothers receiving DI benefi ts.

If you are a victim of a crime, contact the California Victim Compensation program at 1-800-777-9229 (TTY 1-800-735-2929). You may also contact your county Victim/Witness Assistance Center.

Questions about spousal or parental support obligations should be directed to the District Attorney’s Offi ce for the county that issued the court order.

Questions about child support obligations should be directed to the Department of Child Support Services at 1-866-901-3212 (TTY 1-866-399-4096).

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