)RUP
([SLUHV
(PSOR\PHQW (OLJLELOLW\ 9HULILFDWLRQ
'HSDUWPHQW RI +RPHODQG 6HFXULW\
* * &LWL]HQVKLS DQG,PPLJUDWLRQ 6HUYLFHV
)RUP
ลน67$57 +(5( 5HDG LQVWUXFWLRQV FDUHIXOO\ EHIRUH FRPSOHWLQJ WKLV IRUP 7KH LQVWUXFWLRQV PXVW EH DYDLODEOH HLWKHU LQ SDSHU RU HOHFWURQLFDOO\ GXULQJ FRPSOHWLRQ RI WKLV IRUP (PSOR\HUV DUH OLDEOH IRU HUURUV LQ WKH FRPSOHWLRQ RI WKLV IRUP
$17 6&5,0,1$7,21 127 W LV LOOHJDO WR GLVFULPLQDWH DJDLQVW ZRUN DXWKRUL]HG LQGLYLGXDOV (PSOR\HUV &$1127 VSHFLI\ ZKLFK GRFXPHQW V DQ HPSOR\HH PD\ SUHVHQW WR HVWDEOLVK HPSOR\PHQW DXWKRUL]DWLRQ DQG LGHQWLW\ 7KH UHIXVDO WR KLUH RU FRQWLQXH WR HPSOR\ DQ LQGLYLGXDO EHFDXVH WKH GRFXPHQWDWLRQ SUHVHQWHG KDV D IXWXUH H[SLUDWLRQ GDWH PD\ DOVR FRQVWLWXWH LOOHJDO GLVFULPLQDWLRQ 6HFWLRQ PSOR\HH,QIRUPDWLRQ DQG $WWHVWDWLRQ (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
/DVW 1DPH (Family Name) )LUVW 1DPH (Given Name) 0LGGOH,QLWLDO 2WKHU /DVW 1DPHV 8VHG (if any)
$GGUHVV (Street Number and Name) $SW 1XPEHU &LW\ RU 7RZQ 6WDWH =,3 &RGH
'DWH RI %LUWK (mm/dd/yyyy)
8 6 6RFLDO 6HFXULW\ 1XPEHU (PSOR\HH V ( PDLO $GGUHVV (PSOR\HH V 7HOHSKRQH 1XPEHU
$ FLWL]HQ RI WKH 8QLWHG 6WDWHV
$ QRQFLWL]HQ QDWLRQDO RI WKH 8QLWHG 6WDWHV (See instructions)
$ ODZIXO SHUPDQHQW UHVLGHQW
$Q DOLHQ DXWKRUL]HG WR ZRUN XQWLO
(See instructions)
H[SLUDWLRQ GDWH LI DSSOLFDEOH PP GG
$OLHQ 5HJLVWUDWLRQ 1XPEHU 86&,6 1XPEHU
6RPH DOLHQV PD\ ZULWH 1 LQ WKH H[SLUDWLRQ GDWH ILHOG
, DP DZDUH WKDW IHGHUDO ODZ SURYLGHV IRU LPSULVRQPHQW DQG RU ILQHV IRU IDOVH VWDWHPHQWV RU XVH RI IDOVH GRFXPHQWV LQ FRQQHFWLRQ ZLWK WKH FRPSOHWLRQ RI WKLV IRUP
, DWWHVW XQGHU SHQDOW\ RI SHUMXU\ WKDW, DP FKHFN RQH RI WKH IROORZLQJ ER[HV 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.
$OLHQ 5HJLVWUDWLRQ 1XPEHU 86&,6 1XPEHU
)RUP GPLVVLRQ 1XPEHU
)RUHLJQ 3DVVSRUW 1XPEHU
&RXQWU\ RI,VVXDQFH
25
25
45 &RGH 6HFWLRQ
'R 1RW :ULWH,Q 7KLV 6SDFH
6LJQDWXUH RI (PSOR\HH 7RGD\ V 'DWH (mm/dd/yyyy)
3UHSDUHU DQG RU 7UDQVODWRU &HUWLILFDWLRQ FKHFN RQH
, GLG QRW XVH D SUHSDUHU RU WUDQVODWRU $ SUHSDUHU V DQG RU WUDQVODWRU V DVVLVWHG WKH HPSOR\HH LQ FRPSOHWLQJ 6HFWLRQ
(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)
, DWWHVW XQGHU SHQDOW\ RI SHUMXU\ WKDW, KDYH DVVLVWHG LQ WKH FRPSOHWLRQ RI 6HFWLRQ RI WKLV IRUP DQG WKDW WR WKH EHVW RI P\ NQRZOHGJH WKH LQIRUPDWLRQ LV WUXH DQG FRUUHFW
6LJQDWXUH RI 3UHSDUHU RU 7UDQVODWRU 7RGD\ V 'DWH (mm/dd/yyyy)
/DVW 1DPH (Family Name) )LUVW 1DPH (Given Name)
$GGUHVV (Street Number and Name) &LW\ RU 7RZQ 6WDWH =,3 &RGH Employer Completes Next Page
3DJH of
)RUP
86&,6
)RUP
20% 1R
([SLUHV
(PSOR\PHQW (OLJLELOLW\ 9HULILFDWLRQ
'HSDUWPHQW RI +RPHODQG 6HFXULW\
8 6 &LWL]HQVKLS DQG,PPLJUDWLRQ 6HUYLFHV
6HFWLRQ PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH 5HYLHZ DQG 9HULILFDWLRQ
(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.")
/DVW 1DPH (Family Name) )LUVW 1DPH (Given Name) 0,
(PSOR\HH,QIR IURP 6HFWLRQ
&LWL]HQVKLS,PPLJUDWLRQ 6WDWXV
/LVW $
,GHQWLW\ DQG (PSOR\PHQW $XWKRUL]DWLRQ,GHQWLW\ (PSOR\PHQW $XWKRUL]DWLRQ 25 /LVW % $1' /LVW &
$GGLWLRQDO,QIRUPDWLRQ 45 &RGH 6HFWLRQV
'R 1RW :ULWH,Q 7KLV 6SDFH
'RFXPHQW 7LWOH
,VVXLQJ $XWKRULW\
'RFXPHQW 1XPEHU
([SLUDWLRQ 'DWH (if any) (mm/dd/yyyy)
'RFXPHQW 7LWOH
,VVXLQJ $XWKRULW\
'RFXPHQW 1XPEHU
([SLUDWLRQ 'DWH (if any) (mm/dd/yyyy)
'RFXPHQW 7LWOH
,VVXLQJ $XWKRULW\
'RFXPHQW 1XPEHU
([SLUDWLRQ 'DWH (if any) (mm/dd/yyyy)
'RFXPHQW 7LWOH
,VVXLQJ $XWKRULW\
'RFXPHQW 1XPEHU
([SLUDWLRQ 'DWH (if any) (mm/dd/yyyy)
'RFXPHQW 7LWOH
,VVXLQJ $XWKRULW\
'RFXPHQW 1XPEHU
([SLUDWLRQ 'DWH (if any) (mm/dd/yyyy)
&HUWLILFDWLRQ DWWHVW XQGHU SHQDOW\ RI SHUMXU\ WKDW, KDYH H[DPLQHG WKH GRFXPHQW V SUHVHQWHG E\ WKH DERYH QDPHG HPSOR\HH
WKH DERYH OLVWHG GRFXPHQW V DSSHDU WR EH JHQXLQH DQG WR UHODWH WR WKH HPSOR\HH QDPHG DQG WR WKH EHVW RI P\ NQRZOHGJH WKH HPSOR\HH LV DXWKRUL]HG WR ZRUN LQ WKH 8QLWHG 6WDWHV 7KH HPSOR\HH V ILUVW GD\ RI HPSOR\PHQW (mm/dd/yyyy) (See instructions for exemptions) 6LJQDWXUH RI (PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH 7RGD\ V 'DWH (mm/dd/yyyy) 7LWOH RI (PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH
/DVW 1DPH RI (PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH )LUVW 1DPH RI (PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH (PSOR\HU V %XVLQHVV RU 2UJDQL]DWLRQ 1DPH
(PSOR\HU V %XVLQHVV RU 2UJDQL]DWLRQ $GGUHVV Street Number and Name &LW\ RU 7RZQ 6WDWH =,3 &RGH 6HFWLRQ 5HYHULILFDWLRQ DQG 5HKLUHV (To be completed and signed by employer or authorized representative.)
$ 1HZ 1DPH (if applicable)
/DVW 1DPH (Family Name) )LUVW 1DPH (Given Name) 0LGGOH,QLWLDO
DWH RI 5HKLUH (if applicable)
'DWH (mm/dd/yyyy)
'RFXPHQW 7LWOH 'RFXPHQW 1XPEHU ([SLUDWLRQ 'DWH (if any (mm/dd/yyyy)
I WKH HPSOR\HH V SUHYLRXV JUDQW RI HPSOR\PHQW DXWKRUL]DWLRQ KDV H[SLUHG SURYLGH WKH LQIRUPDWLRQ IRU WKH GRFXPHQW RU UHFHLSW WKDW HVWDEOLVKHV FRQWLQXLQJ HPSOR\PHQW DXWKRUL]DWLRQ LQ WKH VSDFH SURYLGHG EHORZ
, DWWHVW XQGHU SHQDOW\ RI SHUMXU\ WKDW WR WKH EHVW RI P\ NQRZOHGJH WKLV HPSOR\HH LV DXWKRUL]HG WR ZRUN LQ WKH 8QLWHG 6WDWHV DQG LI WKH HPSOR\HH SUHVHQWHG GRFXPHQW V WKH GRFXPHQW V, KDYH H[DPLQHG DSSHDU WR EH JHQXLQH DQG WR UHODWH WR WKH LQGLYLGXDO 6LJQDWXUH RI (PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH 7RGD\ V 'DWH (mm/dd/yyyy) 1DPH RI (PSOR\HU RU $XWKRUL]HG 5HSUHVHQWDWLYH
3DJH of
/,676 2) 37 2&80(176
$OO GRFXPHQWV PXVW EH 81(;3,5('
(PSOR\HHV PD\ SUHVHQW RQH VHOHFWLRQ IURP /LVW
RU D FRPELQDWLRQ RI RQH VHOHFWLRQ IURP /LVW % DQG RQH VHOHFWLRQ IURP /LVW &
/,67 $
3HUPDQHQW 5HVLGHQW &DUG RU $OLHQ
5HJLVWUDWLRQ 5HFHLSW &DUG )RUP
8 6 3DVVSRUW RU 8 6 3DVVSRUW &DUG
)RUHLJQ SDVVSRUW WKDW FRQWDLQV D
WHPSRUDU VWDPS RU WHPSRUDU\
SULQWHG QRWDWLRQ RQ D PDFKLQH
UHDGDEOH LPPLJUDQW YLVD
(PSOR\PHQW $XWKRUL]DWLRQ 'RFXPHQW
WKDW FRQWDLQV D SKRWRJUDSK )RUP
)RU D QRQLPPLJUDQW DOLHQ DXWKRUL]HG
WR ZRUN IRU D VSHFLILF HPSOR\HU
EHFDXVH RI KLV RU KHU VWDWXV
'RFXPHQWV WKDW (VWDEOLVK
%RWK,GHQWLW\ DQG
(PSOR\PHQW $XWKRUL]DWLRQ
3DVVSRUW IURP WKH )HGHUDWHG 6WDWHV
RI 0LFURQHVLD )60 RU WKH 5HSXEOLF
RI WKH 0DUVKDOO,VODQGV 50, ZLWK
)RUP RU )RUP LQGLFDWLQJ
QRQLPPLJUDQW DGPLVVLRQ XQGHU WKH
&RPSDFW RI )UHH $VVRFLDWLRQ %HWZHHQ
WKH 8QLWHG 6WDWHV DQG WKH )60 RU 50,
E )RUP RU )RUP WKDW KDV
WKH IROORZLQJ
7KH VDPH QDPH DV WKH SDVVSRUW
DQG
$Q HQGRUVHPHQW RI WKH DOLHQ V
QRQLPPLJUDQW VWDWXV DV ORQJ DV
WKDW SHULRG RI HQGRUVHPHQW KDV
QRW \HW H[SLUHG DQG WKH
SURSRVHG HPSOR\PHQW LV QRW LQ
FRQIOLFW ZLWK DQ\ UHVWULFWLRQV RU
OLPLWDWLRQV LGHQWLILHG RQ WKH IRUP
D )RUHLJQ SDVVSRUW DQG
)RU SHUVRQV XQGHU DJH ZKR DUH
XQDEOH WR SUHVHQW D GRFXPHQW
OLVWHG DERYH
'ULYHU V OLFHQVH RU FDUG LVVXHG E\ D
6WDWH RU RXWO\LQJ SRVVHVVLRQ RI WKH
8QLWHG 6WDWHV SURYLGHG LW FRQWDLQV D
SKRWRJUDSK RU LQIRUPDWLRQ VXFK DV
QDPH GDWH RI ELUWK JHQGHU KHLJKW H\H
FRORU DQG DGGUHVV
'ULYHU V OLFHQVH LVVXHG E\ D &DQDGLDQ
JRYHUQPHQW DXWKRULW\
6FKRRO FDUG ZLWK D SKRWRJUDSK
0LOLWDU\ GHSHQGHQW V FDUG
8 6 &RDVW *XDUG 0HUFKDQW 0DULQHU
&DUG
1DWLYH $PHULFDQ WULEDO GRFXPHQW
6FKRRO UHFRUG RU UHSRUW FDUG
&OLQLF GRFWRU RU KRVSLWDO UHFRUG
'D\ FDUH RU QXUVHU\ VFKRRO UHFRUG
,' FDUG LVVXHG E\ IHGHUDO VWDWH RU ORFDO
JRYHUQPHQW DJHQFLHV RU HQWLWLHV
SURYLGHG LW FRQWDLQV D SKRWRJUDSK RU
LQIRUPDWLRQ VXFK DV QDPH GDWH RI ELUWK
JHQGHU KHLJKW H\H FRORU DQG DGGUHVV
9RWHU V UHJLVWUDWLRQ FDUG
8 6 0LOLWDU\ FDUG RU GUDIW UHFRUG
'RFXPHQWV WKDW (VWDEOLVK
,GHQWLW\
/,67 %
25 $1'
/,67 &
(PSOR\PHQW DXWKRUL]DWLRQ
GRFXPHQW LVVXHG E\ WKH
'HSDUWPHQW RI +RPHODQG 6HFXULW\
$ 6RFLDO 6HFXULW\ $FFRXQW 1XPEHU
FDUG XQOHVV WKH FDUG LQFOXGHV RQH RI
WKH IROORZLQJ UHVWULFWLRQV
&HUWLILFDWLRQ RI UHSRUW RI ELUWK LVVXHG
E\ WKH 'HSDUWPHQW RI 6WDWH )RUPV
'6 )6 )6
2ULJLQDO RU FHUWLILHG FRS\ RI ELUWK
FHUWLILFDWH LVVXHG E\ D 6WDWH
FRXQW\ PXQLFLSDO DXWKRULW\ RU
WHUULWRU\ RI WKH 8QLWHG 6WDWHV
EHDULQJ DQ RIILFLDO VHDO
1DWLYH $PHULFDQ WULEDO GRFXPHQW
,GHQWLILFDWLRQ &DUG IRU 8VH RI
5HVLGHQW &LWL]HQ LQ WKH 8QLWHG
6WDWHV )RUP
'RFXPHQWV WKDW (VWDEOLVK
(PSOR\PHQW $XWKRUL]DWLRQ
8 6 &LWL]HQ DUG )RUP
9 )25 :25. 21 7+
,16 $87+25,=$7,21
9 )25 :25. 21 7+
'+6 $87+25,=$7,21
127 9 )25 (03/2<0(17
)RUP
([DPSOHV RI PDQ\ RI WKHVH GRFXPHQWV DSSHDU LQ WKH +DQGERRN IRU (PSOR\HUV 0 5HIHU WR WKH LQVWUXFWLRQV IRU PRUH LQIRUPDWLRQ DERXW DFFHSWDEOH UHFHLSWV
3DJH of