PLEASE RETURN THE FOLLOWING:

_______________ 1. Completed application and information sheet.

_______________ 2. Fingerprinting process completed - BCII & FBI. May be completed in the Personnel off ce for a fee of $46.00.

_______________ 3. Completed Federal Withholding Tax Form.

_______________ 4. Completed State Withholding Tax Form.

_______________ 5. Completed Employment Eligibility Verif cation Form. (Complete Part I and Read Part II, One document from either List A or List B, along with one document from List C must be personally delivered to the Personnel Off ce for verif cation.) The link for the I-9 form is located at bottom of this packet. If you have diff cult time with the link, this document may be completed in the Personnel Off ce.

________________ 6. Original of your teaching certif cate. A copy will be made and the original returned to you. ________________ 7. Off cial transcripts of your college coursework.

________________ 8. College credentials or two letters of teaching reference.

________________ 9. A tuberculin test showing you to be free from active tuberculosis must be f led with our off ce prior to your f rst day of employment. This test must have been taken within ninety (90) days of your date of employment. The Personnel Off ce will provide you with information about obtaining a test at a nominal charge.

________________ 10. State of Ohio New Hire Reporting Form, and State of Ohio Fraud Complaint Information.

________________ 11. Completed SSA-1945 Form

________________ 12. Ohio Department of Public Safety.

________________ 13. Take picture for ID badge in personnel.

Until all of the above information (items 1-14) has been received and verif ed by the Personnel Off ce, it will be impossible to process your application for employment. DO NOT MAIL. Packet must be returned in person, please call for an appointment.

ANY QUESTIONS, CHANGES OF ADDRESS, ETC., SHOULD BE DIRECTED TO: Debby Shannahan 390 Fair Street, Berea, OH 44017 T elephone: 1-216-898-8300 - Ext. 6235

BEREA CITY SCHOOL DISTRICTBerea, OH 44017

SUBSTITUTE/RESERVE TEACHER APPLICANT CHECKLIST

1/10

BEREA CITY SCHOOL DISTRICTBerea, OH 44017

RESERVE TEACHER INFORMATION SHEET

PERSONAL DATA

1. Name ______________________________________________ S.S. # _________________________

2. Address ___________________________________________________________________________

_ Name of Husband or Wife:

3. Maiden Name ______________________________________ ______________________________

4. Telephone __________________________________________

PROFESSIONAL DATA

1. Indicate the level or levels in which you are prepared and willing to teach and give your preference by ranking1, 2 ,3 , with 1 being your first preference.

HIGH SCHOOL ( ) MIDDLE SCHOOL ( ) ELEMENTARY ( )

If secondary education, list the subject(s) you are certified to teach:

__________________________________________________________________________________

2. Indicate other subjects you would be willing to cover outside your area of certification:

__________________________________________________________________________________

3. If your application is for a position at the elementary level, please indicate if you would accept assignments in the6th, 7th and 8th grades.

Yes ____________ No _________ If yes, what subjects would you be willing to cover?

__________________________________________________________________________________

4. Are you interested in securing a full-time position? Yes __________ No ___________

5. Are you willing to substitute at all the elementary and secondary schools of the Berea City School District?Yes ____________ No _________ . If checked no, please specify area and/or schools where you would be

willing to teach ______________________________________________________________________

_____________________________________________________________________

6. Indicate the days of the week you can teach:

( ) Monday ( ) Tuesday ( ) Wednesday ( ) Thursday ( ) Friday ( ) Every Day

Educational/employment opportunities are offered without regard to race, color, national origin, sex and handicap.

6/96

Do you hold an Ohio Certif cate/License? Yes ___ No ____ Date Issued ____________________ Expires _____________________List all grades, subject matter or other area(s) of specialization which appear on your Ohio Certif cate/License ___________________ __________________________________________________________________________________________________________

Certifi cate: _____ Provisional (4 yr.) ____ Professional (8 yr.) ____ Permanent License: _____ Provisional (2yr.) ____ Professional LIcense (5 yr.)

When would you be available to begin work? ______________________________________________________________________ All applicants must possess or be eligible for a valid teacher's certif cate/license issued by the Ohio Department of Education.

BEREA CITY SCHOOL DISTRICTMiddleburg HeightsBrook ParkBerea

EQUAL OPPORTUNITY EMPLOYERThe Berea Board of Education observes equal opportunity laws with respect to nondiscrimination on the basis of sex, race, sexual orien-tation, color, creed, age, national origin and disability in the recruitment and hiring of employees, in job assignment or classif cation, and in compensation and fringe benef ts.

SPECIAL NOTE: Applicants who require a reasonable accommodation to complete this employment application should contact the Berea City School District Personnel off ce 440-243-6000.

Telephone 216 898-8300 FAX 216 898-8553

APPLICATION FOR PROFESSIONAL EMPLOYMENT

Please Print or Type

Date Social Security No.

Name: Last First Middle

Present Address: Number Street Email

City State Zip Telephone ( )

Permanent Address: (if different from above) Number Street

City State Zip Telephone ( )

Person to Contact If Not Available At Above Address: Name Street City , State Telephone ( )

Give any name other than the one above under which your education or work records may be listed: Last First Middle

Return to:Director of Personnel and Employee Relations 390 Fair Street Berea, Ohio 44017

7/10

PUPIL SERVICES________ Guidance Counselor________ School Psychologist________ Speech and Hearing________ S.B.H.________ S.L.D.________ M.H.________ D.H.________ Mild/Moderate________ Moderate/Intensive________ Other

POSITION(S) APPLYING FOR:TIME ________ Full Time ________ Part Time

POSITION________ Regular Teaching________ Reserve Teaching________ Tutoring________ Administrative/Supervisory________ Adult Education

SUBJECT________ Art________ Health________ Language Arts________ Math________ Music________ Physical Education________ Reading________ Science________ Social Studies________

GRADE LEVEL________ Grades Pre-K-3________ Grades K-8________ Grades 1-8________ Grades 4-9________ Grades 7-12________ Grades 9-12________ Grades K-12

STUDENT TEACHING

Name and Location of School ____________________________

____________________________________________________From (month-year): _________To (month-year): _____________

Grade or Subject ___________Building Principal _____________

Supervising Teacher ___________________________________

List below all the places where you have held positions in education:

SCHOOL AND LOCATION GRADES SUBJECTS/ADMINISTRATIVE FROM TO

REFERENCES: Please use professional references who have knowledge of your teaching/administrative abilities. If your references are up-to-date on f le with the college or university from which you graduated, just list address of college or university . Do not duplicate the references used at the placement service.

NAME TITLE AND PLACE OF EMPLOYMENT TELEPHONE NUMBER

( ) ( ) ( ) ( )

College Credentials: I will request _____________ You may request ____________ Not registered _________

Name used at college, if different from present name: _______________________________________________________________ __________________________________________________________________________________________________________

EDUCATIONAL AND PROFESSIONAL TRAINING:

SCHOOL NAME AND LOCATION OF SCHOOL DIPLOMA ORDEGREE RECEIVED

High School

College orUniversity

College orUniversity

Special Courses

STUDENT TEACHING

Name and Location of School ____________________________

____________________________________________________From (month-year): _________To (month-year): _____________

Grade or Subject ___________Building Principal _____________

Supervising Teacher ___________________________________

PROFESSIONAL STATUS:

Teaching/Administrative ExperienceYears at Years at Middle Years at High Total YearsElementary Level School Level School Level Experience

Are you presently employed ? _________________ If "yes" where? _______________________________________________

What is your current salary or salary in your last position? ____________________________________________________________

Are you under contract for the coming school year? __________Where? ________________________________________________

Have you ever taught under a Continuing Contract in the State of Ohio? __ If yes, When? __________________________________

Where? ___________________________________________________________________________________________________

Have you ever held a contract of employment as a teacher which has not been renewed? ___________________________________

If "yes" specify name of school district and year of contract involved. ___________________________________________________ EXTRA CURRICULAR ACTIVITIES:Check any of the following activities which you are willing and able to direct, coach, supervise or sponsor:___________Debate ___________Cheerleading __________ Volleyball___________Drama ___________National Honor Society __________ Wrestling___________Orchestra ___________Flagbearer __________ Swimming___________Band ___________Football __________ Gymnastics___________Chorus ___________Basketball __________ Water Polo___________Class Advisor ___________Softball __________ Intramurals___________Yearbook ___________Golf __________ Cross Country___________School Newspaper ___________Track __________ Soccer___________Student Council ___________Tennis __________ Baseball___________Other - Please specify _____________________________________________________________________________

List any high school or college extra curricular activities in which you participated.

High School: _______________________________________________________________________________________________

College: ___________________________________________________________________________________________________

List any experience you have had which will help you successfully direct, coach or supervise an extra curricular activity:__________________________________________________________________________________________________________

PERSONAL DATA:Can you perform the essential functions of the job for which you are applying with or without reasonable accommodations? Yes ____ No ____ If you require an accommodation, what kind of reasonable accommodation(s) do you need to perform the essential function of the job for which you are applying? _________________________________________________________________________________ _______________________________________________________________________

Have you ever pleaded "guilty" or "no contest to or been convicted of a misdemeanor or felony violation of the laws of Ohio , any other state, or the United States? Include any expunged pleas or convictions. Yes ___ No ___

If "yes" to the above, please explain on a separate sheet each misdemeanor or felony plea or conviction, including, but not

Should you come under f nal consideration for a position in the Berea City School District, Ohio Revised Code #3319.39 requires the District to request that the Bureau of Criminal Identif cation and Investigation (BCII) conduct a criminal history record check and requires you to submit a set of f ngerprints to the BCII. Employment by the District is conditional on satisfactorily passing the criminal history records check.

I hereby certify that the above information, to the best of my knowledge, is true, accurate, and complete. Any falsif cation of this record would be suff cient cause for disqualif cation and, if employed, discharge. Furthermore, it is understood that this application becomes the property of the Board of Education, which reserves the right to accept or reject it. I authorize the veri f cation of all references and information contained in this application and regard this information as conf dential, not to be revealed to me.

ALL APPLICANTS COMPLETE THE FOLLOWING

Signature of Applicant Date

Signature of Applicant Date

CANDIDATE'S SECTIONPlease complete this section in your handwriting. If more room is needed, attach a separate sheet. Write a brief statement adding any information which will provide us with a more complete estimate of your abilities and qualif cations.

My signature below authorizes the school district to conduct a background investigation and authorizes release of information in connection with my application for employment. This investigation may include, but is not limited to, such information as criminal convictions, driving records, references from previous employers and educational institutions, personal references, professional references, and other appropriate sources. I waive my right to ac-cess to any such information, and without limitation hereby release the school district and the reference source from any liability in connection with its release or use. This release includes the sources cited above and specif c examples as follows: the local Sheriff, information from the Bureau of Criminal Identif cation and Investigation of either data on all criminal convictions or certif cation that no data on criminal convictions are maintained, informa-tion from the Ohio or other State Department of Social Services Unit and any Locality to which they may refer for release of information pertaining to any f ndings of child abuse or neglect investigations involving me.

I also accept that I may be conditionally employed pending the receipt of information from the above sources and may be dismissed based upon the contents of the information.

STATEMENT AND RELEASE FOR BACKGROUND INFORMATION

A personal resume and any additional information may be included with this application. ____________________________

State of Ohio New Hire Reporting Form 7048

Effective October 1, 1997, aI/ Ohio employers are required to report certain information about employees who have been newly hired, rehired, or have retumed to work. Employers must either (1) complete this form, ill (2) submit a copy of the employee's IRS W-4 form with the "other information section" completed on this form, or (3) submit the information by email, electronic tape or floppy diskette. Call 1-888-872-1490 to obtain infonnation on submitting new hire reports electronically. Reports must be made within 20 calendar days of date of hire.

To ensure accuracy, please print (or type) neatly in upper-case letters and numbers using a dark ballpoint pen

MANDATORY INFORMATION EMPLOYEE INFORMATION:

Social security Number: ______ _ State of Hire: ______ _

Name: ____________________________________ ___

First Middle Last

Address 1: ____________________________ _

Address 2: _____________________________ _

Address 3: _ _____________________________ _

City/State/Zip: ______________________________ _

Employee Date of Hire: ________ _ Date of Birth: __________ _

EMPLOYER INFORMATION:

Employer Federal EIN: 346000245

Employer Name: Berea City Schools

Payroll Address: 390 Fair Street

Addross2: ________________________________ _

Addross3: _______________________________ _

City/State/Zip.: __ -=B.:.er:.e:::a:;;>:.....::O.::h.:.i;:..o_4.:..4:..:0:..:1~7_-.:.2:.30:.:8~ ______ ----------_

REPORTS WILL NOT BE PROCESSED WITHOUT MANDATORY INFORMATION Send Reports to:

Ohio New Hire Reporting Center Box 15309 Columbus, Ohio 43215-0309 Fax: (614) 221-7088 or (888) 872-1611

The State of Ohio has established a reporting system whereby public employees can file complaints of fraud and misuse of public funds by public offices or officials.  Complaints can be made using any of the following methods:

1.  Mail a written complaint to:                 Ohio Auditor of State’s Office                 Special Investigations Unit                 88 East Broad Street                 Columbus, Ohio 43215

2.  Report a complaint online by going to:                http://www.auditor.state.oh.us/fraudcenter, then click on “Report Fraud Online”.

3.  Report a complaint by telephone by calling:                  1‐866‐FRAUD‐OH (866‐372‐8364)    I acknowledge receipt of this information:                                Signature                  Date

PRINTED NAME

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#

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)

HLS 0037 2/06 Page 1 of 2

*************************** FOR INSTRUCTIONAL USE ONLY ***************************

READ BEFORE COMPLETING YOUR DMA FORM

Forms not conforming to the specifications listed below or not submitted to the appropriate agency or office will not be processed. • To complete this form, you will need a copy of the Terrorist Exclusion List for reference. The Terrorist Exclusion List

can be found on the Ohio Homeland Security Web site at the following address:

http://www.homelandsecurity.ohio.gov/dma.asp

• Be sure you have the correct DMA form. If you are applying for a state issued license, permit, certification or registration, the “State Issued License” DMA form must be completed (HLS 0036). If you are applying for employment with a government entity, the “Public Employment” DMA form must be completed (HLS 0037). If you are obtaining a contract to conduct business with or receive funding from a government entity, the “Government Business and Funding Contracts” DMA form must be completed (HLS 0038). The Pre-certification form (HLS 0035) should only be completed if you are specifically instructed to do so by the agency or office requesting the form.

• Your DMA form is to be submitted to the issuing agency or entity. “Issuing agency or entity” means the government agency or office that has requested the form from you or the government agency or office to which you are applying for a license, employment or a business contract. For example, if you are seeking a business contract with the Ohio Department of Commerce’s Division of Financial Institutions, then the form needs to be submitted to the Department of Commerce’s Division of Financial Institutions. Do NOT send the form to the Ohio Department of Public Safety UNLESS you are seeking a license from or employment or business contract with one of its eight divisions listed below.

• Department of Public Safety Divisions: Administration Ohio Bureau of Motor Vehicles Ohio Emergency Management Agency Ohio Emergency Medical Services

Ohio Homeland Security* Ohio Investigative Unit Ohio Criminal Justice Services Ohio State Highway Patrol

• * DO NOT SEND THE FORM TO OHIO HOMELAND SECURITY UNLESS OTHERWISE DIRECTED. FORMS SENT TO THE WRONG AGENCY OR ENTITY WILL NOT BE PROCESSED.

*************************** FOR INSTRUCTIONAL USE ONLY ***************************

HLS 0037 2/06 Page 2 of 2

Ohio Department of Public Safety DIVISION OF HOMELAND SECURITY

http://www.homelandsecurity.ohio.gov

PUBLIC EMPLOYMENT

In accordance with section 2909.34 of the Ohio Revised Code DECLARATION REGARDING MATERIAL ASSISTANCE/NO ASSISTANCE TO A TERRORIST ORGANIZATION

This form serves as a declaration of the provision of material assistance to a terrorist organization or organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List (see the Ohio Homeland Security Division Web site for the Terrorist Exclusion List). Any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided. Failure to disclose the provision of material assistance to such an organization or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree. For the purposes of this declaration, “material support or resources” means currency, payment instruments, other financial securities, funds, transfer of funds, and financial services that are in excess of one hundred dollars, as well as communications, lodging, training, safe houses, false documentation or identification, communications equipment, facilities, weapons, lethal substances, explosives, personnel, transportation, and other physical assets, except medicine or religious materials.

LAST NAME FIRST NAME MIDDLE INITIAL

HOME ADDRESS

CITY STATE ZIP COUNTY

HOME PHONE

( ) WORK PHONE

( )

DECLARATION In accordance with section 2909.32 (A)(2)(b) of the Ohio Revised Code For each question, indicate either “yes,” or “no” in the space provided. Responses must be truthful to the best of your knowledge. 1. Are you a member of an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 2. Have you used any position of prominence you have with any country to persuade others to support an organization

on the U.S. Department of State Terrorist Exclusion List? Yes No 3. Have you knowingly solicited funds or other things of value for an organization on the U.S. Department of State

Terrorist Exclusion List? Yes No 4. Have you solicited any individual for membership in an organization on the U.S. Department of State Terrorist

Exclusion List? Yes No 5. Have you committed an act that you know, or reasonably should have known, affords "material support or resources"

to an organization on the U.S. Department of State Terrorist Exclusion List? Yes No 6. Have you hired or compensated a person you knew to be a member of an organization on the U.S. Department of

State Terrorist Exclusion List, or a person you knew to be engaged in planning, assisting, or carrying out an act of terrorism? Yes No

In the event of a denial of licensure due to a positive indication that material assistance has been provided to a terrorist organization, or an organization that supports terrorism as identified by the U.S. Department of State Terrorist Exclusion List, a review of the denial may be requested. The request must be sent to the Ohio Department of Public Safety’s Division of Homeland Security. The request forms and instructions for filing can be found on the Ohio Homeland Security Division Web site. CERTIFICATION I hereby certify that the answers I have made to all of the questions on this declaration are true to the best of my knowledge. I understand that if this declaration is not completed in its entirety, it will not be processed and I will be automatically disqualified. I understand that I am responsible for the correctness of this declaration. I understand that failure to disclose the provision of material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List, or knowingly making false statements regarding material assistance to such an organization is a felony of the fifth degree. I understand that any answer of “yes” to any question, or the failure to answer “no” to any question on this declaration shall serve as a disclosure that material assistance to an organization identified on the U.S. Department of State Terrorist Exclusion List has been provided by myself or my organization. If I am signing this on behalf of a company, business or organization, I hereby acknowledge that I have the authority to make this certification on behalf of the company, business or organization referenced above. X APPLICANT SIGNATURE DATE

CLICK ON 

ATTACHMENT 

FORM I‐9, 

EMPLOYMENT 

ELIGIBILITY 

VERIFICATION 

BELOW 

IT 4Rev. 5/07

Employee’s Withholding Exemption Certificate

Print full name Social Security number

Home address and ZIP code

Public school district of residence School district no.(See The Finder at tax.ohio.gov.)

1. Personal exemption for yourself, enter “1” if claimed ...............................................................................................................

2. If married, personal exemption for your spouse if not separately claimed (enter “1” if claimed) ............................................

3. Exemptions for dependents .......................................................................................................................................................

4. Add the exemptions that you have claimed above and enter total ...........................................................................................

5. Additional withholding per pay period under agreement with employer ..................................................................................

Under the penalties of perjury, I certify that the number of exemptions claimed on this certificate does not exceed the number to which I am entitled.

Signature Date

IT 4Rev. 5/07

$

✁✁✁✁✁ please detach here

Notice to Employee

1. For state purposes, an individual may claim only natural de-pendency exemptions. This includes the taxpayer, spouseand each dependent. Dependents are the same as definedin the Internal Revenue Code and as claimed in the taxpayer’sfederal income tax return for the taxable year for which thetaxpayer would have been permitted to claim had the tax-payer filed such a return.

2. You may file a new certificate at any time if the number of yourexemptions increases.

You must file a new certificate within 10 days if the number ofexemptions previously claimed by you decreases because:(a) Your spouse for whom you have been claiming exemp-

tion is divorced or legally separated, or claims her (or his)own exemption on a separate certificate.

(b) The support of a dependent for whom you claimed ex-emption is taken over by someone else.

(c) You find that a dependent for whom you claimed exemp-tion must be dropped for federal purposes.

The death of a spouse or a dependent does not affect yourwithholding until the next year but requires the filing of a newcertificate. If possible, file a new certificate by Dec. 1st of theyear in which the death occurs.

For further information, consult the Ohio Department of Taxa-tion, Personal and School District Income Tax Division, oryour employer.

3. If you expect to owe more Ohio income tax than will bewithheld, you may claim a smaller number of exemptions;or under an agreement with your employer, you may havean additional amount withheld each pay period.

4. A married couple with both spouses working and filing ajoint return will, in many cases, be required to file an indi-vidual estimated income tax form IT 1040ES even thoughOhio income tax is being withheld from their wages. Thisresult may occur because the tax on their combined in-come will be greater than the sum of the taxes withheldfrom the husband’s wages and the wife’s wages. Thisrequirement to file an individual estimated income tax formIT 1040ES may also apply to an individual who has twojobs, both of which are subject to withholding. In lieu offiling the individual estimated income tax form IT 1040ES,the individual may provide for additional withholding withhis employer by using line 5.

hio Department ofTaxation

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

Anti-Discrimination Notice. It is illegal to discriminate against any individual (other than an alien not authorized to work in the United States) in hiring, discharging, or recruiting or referring for a fee because of that individual's national origin or citizenship status. It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents presented have a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration Related Unfair Employment Practices at 1-800-255-8155.

All employees (citizens and noncitizens) hired after November 6, 1986, and working in the United States must complete Form I-9.

OMB No. 1615-0047; Expires 08/31/12

The Preparer/Translator Certification must be completed if Section 1 is prepared by a person other than the employee. A preparer/translator may be used only when the employee is unable to complete Section 1 on his or her own. However, the employee must still sign Section 1 personally.

Form I-9 (Rev. 08/07/09) Y

Read all instructions carefully before completing this form. Instructions

When Should Form I-9 Be Used?

What Is the Purpose of This Form?

The purpose of this form is to document that each new employee (both citizen and noncitizen) hired after November 6, 1986, is authorized to work in the United States.

For the purpose of completing this form, the term "employer" means all employers including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors. Employers must complete Section 2 by examining evidence of identity and employment authorization within three business days of the date employment begins. However, if an employer hires an individual for less than three business days, Section 2 must be completed at the time employment begins. Employers cannot specify which document(s) listed on the last page of Form I-9 employees present to establish identity and employment authorization. Employees may present any List A document OR a combination of a List B and a List C document.Filling Out Form I-9

This part of the form must be completed no later than the time of hire, which is the actual beginning of employment. Providing the Social Security Number is voluntary, except for employees hired by employers participating in the USCIS Electronic Employment Eligibility Verification Program (E-Verify). The employer is responsible for ensuring that Section 1 is timely and properly completed.

1. Document title;2. Issuing authority;3. Document number;4. Expiration date, if any; and 5. The date employment begins.

Employers must sign and date the certification in Section 2. Employees must present original documents. Employers may, but are not required to, photocopy the document(s) presented. If photocopies are made, they must be made for all new hires. Photocopies may only be used for the verification process and must be retained with Form I-9. Employers are still responsible for completing and retaining Form I-9.

Noncitizen nationals of the United States are persons born in American Samoa, certain former citizens of the former Trust Territory of the Pacific Islands, and certain children of noncitizen nationals born abroad.

Employers should note the work authorization expiration date (if any) shown in Section 1. For employees who indicate an employment authorization expiration date in Section 1, employers are required to reverify employment authorization for employment on or before the date shown. Note that some employees may leave the expiration date blank if they are aliens whose work authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia or the Republic of the Marshall Islands). For such employees, reverification does not apply unless they choose to present

If an employee is unable to present a required document (or documents), the employee must present an acceptable receipt in lieu of a document listed on the last page of this form. Receipts showing that a person has applied for an initial grant of employment authorization, or for renewal of employment authorization, are not acceptable. Employees must present receipts within three business days of the date employment begins and must present valid replacement documents within 90 days or other specified time.

Employers must record in Section 2:

Preparer/Translator Certification

Section 2, Employer

Section 1, Employee

in Section 2 evidence of employment authorization that contains an expiration date (e.g., Employment Authorization Document (Form I-766)).

EMPLOYERS MUST RETAIN COMPLETED FORM I-9 DO NOT MAIL COMPLETED FORM I-9 TO ICE OR USCIS

To order USCIS forms, you can download them from our website at www.uscis.gov/forms or call our toll-free number at 1-800-870-3676. You can obtain information about Form I-9 from our website at www.uscis.gov or by calling 1-888-464-4218.

USCIS Forms and Information

What Is the Filing Fee?

There is no associated filing fee for completing Form I-9. This form is not filed with USCIS or any government agency. Form I-9 must be retained by the employer and made available for inspection by U.S. Government officials as specified in the Privacy Act Notice below.

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

Privacy Act Notice

This information is for employers to verify the eligibility of individuals for employment to preclude the unlawful hiring, or recruiting or referring for a fee, of aliens who are not authorized to work in the United States.

A blank Form I-9 may be reproduced, provided both sides are copied. The Instructions must be available to all employees completing this form. Employers must retain completed Form I-9s for three years after the date of hire or one year after the date employment ends, whichever is later.

Photocopying and Retaining Form I-9

Form I-9 may be signed and retained electronically, as authorized in Department of Homeland Security regulations at 8 CFR 274a.2.C. If an employee is rehired within three years of the date

this form was originally completed and the employee's work authorization has expired or if a current employee's work authorization is about to expire (reverification), complete Block B; and:

1. Examine any document that reflects the employee is authorized to work in the United States (see List A or C);

2. Record the document title, document number, and expiration date (if any) in Block C; and

3. Complete the signature block.

A. If an employee's name has changed at the time this form is being updated/reverified, complete Block A.

B. If an employee is rehired within three years of the date this form was originally completed and the employee is still authorized to be employed on the same basis as previously indicated on this form (updating), complete Block B and the signature block.

Employers must complete Section 3 when updating and/or reverifying Form I-9.  Employers must reverify employment authorization of their employees on or before the work authorization expiration date recorded in Section 1 (if any).  Employers CANNOT specify which document(s) they will accept from an employee.

For more detailed information, you may refer to the USCIS Handbook for Employers (Form M-274). You may obtain the handbook using the contact information found under the header "USCIS Forms and Information."

Note that for reverification purposes, employers have the option of completing a new Form I-9 instead of completing Section 3.

Information about E-Verify, a free and voluntary program that allows participating employers to electronically verify the employment eligibility of their newly hired employees, can be obtained from our website at www.uscis.gov/e-verify or by calling 1-888-464-4218.

General information on immigration laws, regulations, and procedures can be obtained by telephoning our National Customer Service Center at 1-800-375-5283 or visiting our Internet website at www.uscis.gov.

This information will be used by employers as a record of their basis for determining eligibility of an employee to work in the United States. The form will be kept by the employer and made available for inspection by authorized officials of the Department of Homeland Security, Department of Labor, and Office of Special Counsel for Immigration-Related Unfair Employment Practices.

Submission of the information required in this form is voluntary. However, an individual may not begin employment unless this form is completed, since employers are subject to civil or criminal penalties if they do not comply with the Immigration Reform and Control Act of 1986.

Section 3, Updating and Reverification

Form I-9 (Rev. 08/07/09) Y Page 2

Paperwork Reduction Act

An agency may not conduct or sponsor an information collection and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. The public reporting burden for this collection of information is estimated at 12 minutes per response, including the time for reviewing instructions and completing and submitting the form. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Citizenship and Immigration Services, Regulatory Management Division, 111 Massachusetts Avenue, N.W., 3rd Floor, Suite 3008, Washington, DC 20529-2210. OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

Form I-9 (Rev. 08/07/09) Y Page 3

Department of Homeland Security U.S. Citizenship and Immigration Services

Form I-9, Employment Eligibility Verification

OMB No. 1615-0047; Expires 08/31/12

Read instructions carefully before completing this form. The instructions must be available during completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documents have a future expiration date may also constitute illegal discrimination.Section 1. Employee Information and Verification (To be completed and signed by employee at the time employment begins.)Print Name: Last First Middle Initial Maiden Name

Address (Street Name and Number) Apt. # Date of Birth (month/day/year)

StateCity Zip Code Social Security #

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.

Employee's Signature Date (month/day/year)

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.) I attest, under penalty of perjury, that I have assisted in the completion of this form and that to the best of my knowledge the information is true and correct.

Address (Street Name and Number, City, State, Zip Code)

Print NamePreparer's/Translator's Signature

Date (month/day/year)

Section 2. Employer Review and Verification (To be completed and signed by employer. Examine one document from List A OR examine one document from List B and one from List C, as listed on the reverse of this form, and record the title, number, and expiration date, if any, of the document(s).)

ANDList B List CORList ADocument title:

Issuing authority:

Document #:

Expiration Date (if any):Document #:

Expiration Date (if any):

and that to the best of my knowledge the employee is authorized to work in the United States. (State(month/day/year)employment agencies may omit the date the employee began employment.)

CERTIFICATION: I attest, under penalty of perjury, that I have examined the document(s) presented by the above-named employee, that the above-listed document(s) appear to be genuine and to relate to the employee named, that the employee began employment on

Print Name TitleSignature of Employer or Authorized Representative

Date (month/day/year)Business or Organization Name and Address (Street Name and Number, City, State, Zip Code)

B. Date of Rehire (month/day/year) (if applicable)A. New Name (if applicable)

C. If employee's previous grant of work authorization has expired, provide the information below for the document that establishes current employment authorization.

Document #: Expiration Date (if any):Document Title:

Section 3. Updating and Reverification (To be completed and signed by employer.) 

l 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) l have examined appear to be genuine and to relate to the individual.

Date (month/day/year)Signature of Employer or Authorized Representative

I attest, under penalty of perjury, that I am (check one of the following):

A lawful permanent resident (Alien #)

A citizen of the United States

An alien authorized to work (Alien # or Admission #)

A noncitizen national of the United States (see instructions)

until (expiration date, if applicable - month/day/year)

Form I-9 (Rev. 08/07/09) Y Page 4

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

LISTS OF ACCEPTABLE DOCUMENTS

LIST A LIST B LIST C

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

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

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

1. Social Security Account Number card other than one that specifies on the face that the issuance of the card does not authorize employment in the United States

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

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

2. Certification of Birth Abroad issued by the Department of State (Form FS-545)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)

3. Certification of Report of Birth issued by the Department of State (Form DS-1350)

3. School ID card with a photograph

5. In the case of a nonimmigrant alien authorized to work for a specific employer incident to status, a foreign passport with Form I-94 or Form I-94A bearing the same name as the passport and containing an endorsement of the alien's nonimmigrant status, as long as the period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form

6.  Military dependent's ID card

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

7. U.S. Coast Guard Merchant Mariner Card

5. Native American tribal document

8.   Native American tribal document

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

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

Illustrations of many of these documents appear in Part 8 of the Handbook for Employers (M-274)

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 Both Identity and Employment

Authorization

Documents that Establish Identity

Documents that Establish Employment Authorization

OR AND

All documents must be unexpired

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

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

Form I-9 (Rev. 08/07/09) Y Page 5