Classified Managerial and Civil Service New Hire Checklist Office of Human Resources

The Graduate Center

Name: Title:

Date of New Hire Orientation: Home Telephone:

ORIENTATION DOCUMENTS: Please bring the completed forms with you to the orientation.

Employment Eligibility Verification - Form I-9 W-4 (Federal Tax Withholding) IT-2104 (State Tax Withholding) Direct Deposit Personnel Data Survey Emergency Contact Information Release of Information Amended Constitutional Oath Upon Appointment

OTHER REQUIRED DOCUMENTS: Please have your college mail an official transcript of your highest degree to:

Attn: Classified Civil service Staff Coordinator

Office of Human Resources

The Graduate Center

365 Fifth Avenue Room 8403 New York, NY 10016

CUNY Employment Application

Pension Enrollment Plan Designation of Beneficiary Fact Sheet New Health Insurance Marketplace Coverage options and

your Health Coverage Commuter Benefits Program Enrollment Form (Wage

Works) o CUNY Information Page (Click here for more information)

POLICIES & INFORMATION: Employees are responsible for knowing all CUNY and The Graduate Center policies. Please review each as part of your appointment.

Agency Shop Fee Charge of Discrimination Form CUNY Policy on Computer Use Domestic Violence Employee Notice of Work Related Injury or Illness

Form Equal Opportunity Employment Program Fire Safety and Emergency Evacuations Hiring and Retention of Individuals with Disabilities Jury Duty Notice of Non-Discrimination Office of Compliance & Diversity Ombuds Office Patient Protection and Affordable Care Act

Report of Injury Security Policies and Crime Reporting Procedures Sexual Misconduct Snow Emergency Closing Procedures Title IX Awareness Tobacco Free CUNY Veterans and Veterans of the Vietnam Era with a

Disability Workplace Violence Policies, Procedures and

Prevention Plans You Have a Right to Know

EMPLOYEE TRAINING: Please complete the following mandatory CUNY training programs. They may be taken online at any time but must be completed before your appointment begins.

IT Security Awareness Policy Title IX Training:

o Policy Highlights o Consent o Bystander Intervention

I have received the links to the policies and employee training programs governing my appointment.

Signature: Date:

Instructions for Employment Eligibility Verification

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

USCISForm I-9

OMB No. 1615-0047Expires 03/31/2016

Read all instructions carefully before completing this form.

Anti-Discrimination Notice. It is illegal to discriminate against any work-authorized individual in hiring, discharge, recruitment or referral for a fee, or in the employment eligibility verification (Form I-9 and E-Verify) process based on that individual's citizenship status, immigration status or national origin. Employers CANNOT specify which document(s) they will accept from an employee. The refusal to hire an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. For more information, call the Office of Special Counsel for Immigration-Related Unfair Employment Practices (OSC) at 1-800-255-7688 (employees), 1-800-255-8155 (employers), or 1-800-237-2515 (TDD), or visit www.justice.gov/crt/about/osc.

Form I-9 Instructions 03/08/13 N Page 1 of 9EMPLOYERS MUST RETAIN COMPLETED FORM I-9

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

What Is the Purpose of This Form?

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

Employers are responsible for completing and retaining Form I-9. For the purpose of completing this form, the term "employer" means all employers, including those recruiters and referrers for a fee who are agricultural associations, agricultural employers, or farm labor contractors.

General Instructions

Section 1. Employee Information and Attestation

Newly hired employees must complete and sign Section 1 of Form I-9 no later than the first day of employment.Section 1 should never be completed before the employee has accepted a job offer. Provide the following information to complete Section 1:

Name: Provide your full legal last name, first name, and middle initial. Your last name is your family name or surname. If you have two last names or a hyphenated last name, include both names in the last name field. Your first name is your given name. Your middle initial is the first letter of your second given name, or the first letter of your middle name, if any. Other names used: Provide all other names used, if any (including maiden name). If you have had no other legalnames, write "N/A." Address: Provide the address where you currently live, including Street Number and Name, Apartment Number (if applicable), City, State, and Zip Code. Do not provide a post office box address (P.O. Box). Only border commuters from Canada or Mexico may use an international address in this field.

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

Employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 6, 1986, to work in the United States. In the Commonwealth of the Northern Mariana Islands (CNMI), employers must complete Form I-9 to document verification of the identity and employment authorization of each new employee (both citizen and noncitizen) hired after November 27, 2011. Employers should have used Form I-9 CNMI between November 28, 2009 and November 27, 2011.

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

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

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

3. A lawful permanent resident: A lawful permanent resident is any person who is not a U.S. citizen and who resides in the United States under legally recognized and lawfully recorded permanent residence as an immigrant. The term "lawful permanent resident" includes conditional residents. If you check this box, write either your Alien Registration Number (A-Number) or USCIS Number in the field next to your selection. At this time, the USCIS Number is the same as the A-Number without the "A" prefix.

4. An alien authorized to work: If you are not a citizen or national of the United States or a lawful permanent resident, but are authorized to work in the United States, check this box.

a. Record the date that your employment authorization expires, if any. Aliens whose employment authorization does not expire, such as refugees, asylees, and certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau, may write "N/A" on this line.

b. Next, enter your Alien Registration Number (A-Number)/USCIS Number. At this time, the USCIS Number is the same as your A-Number without the "A" prefix. If you have not received an A-Number/USCIS Number, record your Admission Number. You can find your Admission Number on Form I-94, "Arrival-Departure Record," or as directed by USCIS or U.S. Customs and Border Protection (CBP).

(1) If you obtained your admission number from CBP in connection with your arrival in the United States, then also record information about the foreign passport you used to enter the United States (number and country of issuance).

(2) If you obtained your admission number from USCIS within the United States, or you entered the United States without a foreign passport, you must write "N/A" in the Foreign Passport Number and Country of Issuance fields.

Sign your name in the "Signature of Employee" block and record the date you completed and signed Section 1. By signing and dating this form, you attest that the citizenship or immigration status you selected is correct and that you are aware that you may be imprisoned and/or fined for making false statements or using false documentation when completing this form. To fully complete this form, you must present to your employer documentation that establishes your identity and employment authorization. Choose which documents to present from the Lists of Acceptable Documents, found on the last page of this form. You must present this documentation no later than the third day after beginning employment, although you may present the required documentation before this date.

The Preparer and/or Translator Certification must be completed if the employee requires assistance to complete Section 1 (e.g., the employee needs the instructions or responses translated, someone other than the employee fills out the information blocks, or someone with disabilities needs additional assistance). The employee must still sign Section 1.

Minors and Certain Employees with Disabilities (Special Placement)

Parents or legal guardians assisting minors (individuals under 18) and certain employees with disabilities should review the guidelines in the Handbook for Employers: Instructions for Completing Form I-9 (M-274) on www.uscis.gov/I-9Central before completing Section 1. These individuals have special procedures for establishing identity if they cannot present an identity document for Form I-9. The special procedures include (1) the parent or legal guardian filling out Section 1 and writing "minor under age 18" or "special placement," whichever applies, in the employee signature block; and (2) the employer writing "minor under age 18" or "special placement" under List B in Section 2.

Preparer and/or Translator Certification

If you check this box:

1. A citizen of the United States

2. A noncitizen national of the United States: 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.

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

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

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

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

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

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

6. Record the employer's business name and address.

7. Return the employee's documentation.

If the employee is a student or exchange visitor who presented a foreign passport with a Form I-94, the employer should also enter in Section 2:a. The student's Form I-20 or DS-2019 number (Student and Exchange Visitor Information System-SEVIS Number);

and the program end date from Form I-20 or DS-2019.

Employers or their authorized representative must:1. Physically examine each original document the employee presents to determine if it reasonably appears to be genuine

and to relate to the person presenting it. The person who examines the documents must be the same person who signs Section 2. The examiner of the documents and the employee must both be physically present during the examination of the employee's documents.

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

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

In the field below the Section 2 introduction, employers must enter the last name, first name and middle initial, if any, that the employee entered in Section 1. This will help to identify the pages of the form should they get separated.

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

Before completing Section 2, employers must ensure that Section 1 is completed properly and on time. Employers may not ask an individual to complete Section 1 before he or she has accepted a job offer.

Section 2. Employer or Authorized Representative Review and Verification

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

2. Write the word "receipt" and its document number in the "Document Number" field. Record the last day that the receipt is valid in the "Expiration Date" field.

1. Record the document title in Section 2 under the sections titled List A, List B, or List C, as applicable.

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

2. Record the number and other required document information from the actual document presented.

3. Initial and date the change.

1. Cross out the word "receipt" and any accompanying document number and expiration date.

By the end of the receipt validity period, the employer should:

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

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

3. The departure portion of Form I-94/I-94A with a refugee admission stamp. The employee must present an unexpiredEmployment Authorization Document (Form I-766) or a combination of a List B document and an unrestricted Social Security card within 90 days.

Section 3. Reverification and Rehires

1. A receipt showing that the employee has applied to replace a document that was lost, stolen or damaged. Theemployee must present the actual document within 90 days from the date of hire.

There are three types of acceptable receipts:

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

Employees must present receipts within 3 business days of their first day of employment, or in the case of reverification, by the date that reverification is required, and must present valid replacement documents within the time frames described below.

If an employee is unable to present a required document (or documents), the employee can present an acceptable receipt in lieu of a document from the Lists of Acceptable Documents 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. Employers cannot accept receipts if employment will last less than 3 days. Receipts are acceptable when completing Form I-9 for a new hire or when reverification is required.

Receipts

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

Unexpired Documents

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

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

b. Record the document title, document number, and expiration date (if any).

3. Complete Block C if:

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

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

To complete Block C:a. Examine either a List A or List C document the employee presents that shows that the employee is currently

authorized to work in the United States; and

2. Complete Block B with the date of rehire if you rehire an employee within 3 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. Also complete the "Signature of Employer or Authorized Representative" block.

1. Complete Block A if an employee's name has changed at the time you complete Section 3.To complete Section 3, employers should follow these instructions:

For reverification, an employee must present unexpired documentation from either List A or List C showing he or she is still authorized to work. Employers CANNOT require the employee to present a particular document from List A or List C. The employee may choose which document to present.

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

Reverification applies if evidence of employment authorization (List A or List C document) presented in Section 2 expires. However, employers should not reverify: 1. U.S. citizens and noncitizen nationals; or2. Lawful permanent residents who presented a Permanent Resident Card (Form I-551) for Section 2.

Reverification does not apply to List B documents.

Some employees may write "N/A" in the space provided for the expiration date in Section 1 if they are aliens whose employment authorization does not expire (e.g., asylees, refugees, certain citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or Palau). Reverification does not apply for such employees unless they chose to present evidence of employment authorization in Section 2 that contains an expiration date and requires reverification, such as Form I-766, Employment Authorization Document.

There is no 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 "USCISPrivacy Act Statement" below.

What Is the Filing Fee?

USCIS Forms and Information

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

4. After completing block A, B or C, complete the "Signature of Employer or Authorized Representative" block, including the date. For reverification purposes, employers may either complete Section 3 of a new Form I-9 or Section 3 of the previously completed Form I-9. Any new pages of Form I-9 completed during reverification must be attached to the employee's original Form I-9. If you choose to complete Section 3 of a new Form I-9, you may attach just the page containing Section 3, with the employee's name entered at the top of the page, to the employee's original Form I-9. If there is a more current version of Form I-9 at the time of reverification, you must complete Section 3 of that version of the form.

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

ROUTINE USES: 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 employer will keep this form and make it 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.

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 35 minutes per response, including the time for reviewing instructions and completing and retaining 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 Coordination Division, Office of Policy and Strategy, 20 Massachusetts Avenue NW, Washington, DC 20529-2140; OMB No. 1615-0047. Do not mail your completed Form I-9 to this address.

USCIS Privacy Act Statement

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

PURPOSE: This information is collected by employers to comply with the requirements of the Immigration Reform and Control Act of 1986. This law requires that employers verify the identity and employment authorization of individuals they hire 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.

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

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

Photocopying and Retaining Form I-9

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

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

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 the USCIS Web site at www.dhs.gov/E-Verify, by e-mailing USCIS at E-Verify@dhs.gov or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.

You can also obtain information about Form I-9 from the USCIS Web site at www.uscis.gov/I-9Central, by e-mailing USCIS at I-9Central@dhs.gov, or by calling 1-888-464-4218. For TDD (hearing impaired), call 1-877-875-6028.

To obtain USCIS forms or the Handbook for Employers, you can download them from the USCIS Web site at www.uscis.gov/forms. You may order USCIS forms by calling our toll-free number at 1-800-870-3676. You may also obtain forms and information by contacting the USCIS National Customer Service Center at 1-800-375-5283. For TDD (hearing impaired), call 1-800-767-1833.

Employment Eligibility Verification

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

USCISForm I-9

OMB No. 1615-0047Expires 03/31/2016

START HERE. Read instructions carefully before completing this form. The instructions must be available during completion of this form.

Section 1. Employee Information and Attestation (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.)

Address (Street Number and Name)

E-mail Address Telephone NumberDate of Birth (mm/dd/yyyy)

Other Names Used (if any)

U.S. Social Security Number

Middle Initial

Apt. Number City or Town State Zip Code

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):

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

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

Address (Street Number and Name) City or Town Zip CodeState

A lawful permanent resident (Alien Registration Number/USCIS Number):

A citizen of the United States

A noncitizen national of the United States (See instructions)

1. Alien Registration Number/USCIS Number:

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

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

2. Form I-94 Admission Number:

Country of Issuance:

Foreign Passport Number:

(See instructions)

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

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

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

Employer Completes Next Page

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.

Preparer and/or Translator Certification (To be completed and signed if Section 1 is prepared by a person other than the employee.)

OR

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

3-D Barcode Do Not Write in This Space

Page 8 of 9Form I-9 03/08/13 N

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

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 examine a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents" on the next page of this form. For each document you review, record the following information: document title, issuing authority, document number, and expiration date, if any.)

CertificationI 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.)

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

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

Last Name (Family Name) Employer's Business or Organization NameFirst Name (Given Name)

City or Town Zip CodeState

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)A. New Name (if applicable) B. Date of Rehire (if applicable) (mm/dd/yyyy):

Document Title: Document Number:

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

Middle InitialFirst Name (Given Name)Last Name (Family Name)

Issuing Authority: Issuing Authority:

Document Number:

Document Title:Document Title:

Document Number:

Issuing Authority:

List A OR ANDList B List C

Document Number:

Document Title:

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

Document Title:

Issuing Authority:

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

Document Title:

Issuing Authority:

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

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

Identity and Employment Authorization Identity Employment Authorization

Document Number:

Document Number:

Print Name of Employer or Authorized Representative:

3-D Barcode Do Not Write in This Space

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

LISTS OF ACCEPTABLE DOCUMENTS

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

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

listed above:

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. A Social Security Account Number card, unless the card

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 photograph5. For a nonimmigrant alien authorized

to work for a specific employer because of his or her status:

6. Military dependent's ID card4. 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 document8. 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

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 EstablishIdentity

Documents that EstablishEmployment 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)

b. Form I-94 or Form I-94A that hasthe 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

Refer to Section 2 of the instructions, titled "Employer or Authorized Representative Review and Verification," for more information about acceptable receipts.

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

Form W-4 (2016)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. If you are exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2016 expires February 15, 2017. See Pub. 505, Tax Withholding and Estimated Tax.Note: If another person can claim you as a dependent on his or her tax return, you cannot claim exemption from withholding if your income exceeds $1,050 and includes more than $350 of unearned income (for example, interest and dividends).

Exceptions. An employee may be able to claim exemption from withholding even if the employee is a dependent, if the employee:• Is age 65 or older,

• Is blind, or

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

The exceptions do not apply to supplemental wages greater than $1,000,000.Basic instructions. If you are not exempt, complete the Personal Allowances Worksheet below. The worksheets on page 2 further adjust your withholding allowances based on itemized deductions, certain credits, adjustments to income, or two-earners/multiple jobs situations.

Complete all worksheets that apply. However, you may claim fewer (or zero) allowances. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.Head of household. Generally, you can claim head of household filing status on your tax return only if you are unmarried and pay more than 50% of the costs of keeping up a home for yourself and your dependent(s) or other qualifying individuals. See Pub. 501, Exemptions, Standard Deduction, and Filing Information, for information.Tax credits. You can take projected tax credits into account in figuring your allowable number of withholding allowances. Credits for child or dependent care expenses and the child tax credit may be claimed using the Personal Allowances Worksheet below. See Pub. 505 for information on converting your other credits into withholding allowances.

Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you may owe additional tax. If you have pension or annuity income, see Pub. 505 to find out if you should adjust your withholding on Form W-4 or W-4P.Two earners or multiple jobs. If you have a working spouse or more than one job, figure the total number of allowances you are entitled to claim on all jobs using worksheets from only one Form W-4. Your withholding usually will be most accurate when all allowances are claimed on the Form W-4 for the highest paying job and zero allowances are claimed on the others. See Pub. 505 for details.Nonresident alien. If you are a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.Check your withholding. After your Form W-4 takes effect, use Pub. 505 to see how the amount you are having withheld compares to your projected total tax for 2016. See Pub. 505, especially if your earnings exceed $130,000 (Single) or $180,000 (Married).Future developments. Information about any future developments affecting Form W-4 (such as legislation enacted after we release it) will be posted at www.irs.gov/w4.

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

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

} B

C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) . . . . . . . . . . . . . . C

D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return . . . . . . . . D

E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) . . E

F Enter “1” if you have at least $2,000 of child or dependent care expenses for which you plan to claim a credit . . . F

(Note: Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.) G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.

• If your total income will be less than $70,000 ($100,000 if married), enter “2” for each eligible child; then less “1” if you have two to four eligible children or less “2” if you have five or more eligible children. • If your total income will be between $70,000 and $84,000 ($100,000 and $119,000 if married), enter “1” for each eligible child . . G

H Add lines A through G and enter total here. (Note: This may be different from the number of exemptions you claim on your tax return.) H

For accuracy, complete all worksheets that apply.

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

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

Separate here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4Department of the Treasury Internal Revenue Service

Employee's Withholding Allowance Certificate Whether you are 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

20161 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, but legally separated, or spouse is a nonresident alien, check the “Single” box.

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

check here. You must call 1-800-772-1213 for a replacement card.

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5

6 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $

7 I claim exemption from withholding for 2016, 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 lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2016)

Form W-4 (2016) Page 2

Deductions and Adjustments Worksheet

Note: Use this worksheet only if you plan to itemize deductions or claim certain credits or adjustments to income.1 Enter an estimate of your 2016 itemized deductions. These include qualifying home mortgage interest, charitable contributions, state

and local taxes, medical expenses in excess of 10% (7.5% if either you or your spouse was born before January 2, 1952) of your income, and miscellaneous deductions. For 2016, you may have to reduce your itemized deductions if your income is over $311,300 and you are married filing jointly or are a qualifying widow(er); $285,350 if you are head of household; $259,400 if you are single and not head of household or a qualifying widow(er); or $155,650 if you are married filing separately. See Pub. 505 for details . . . 1 $

2 Enter: { $12,600 if married filing jointly or qualifying widow(er)$9,300 if head of household . . . . . . . . . . .$6,300 if 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 2016 adjustments to income and any additional standard deduction (see Pub. 505) 4 $5 Add lines 3 and 4 and enter the total. (Include any amount for credits from the Converting Credits to

Withholding Allowances for 2016 Form W-4 worksheet in Pub. 505.) . . . . . . . . . . . . 5 $6 Enter an estimate of your 2016 nonwage income (such as dividends or interest) . . . . . . . . 6 $7 Subtract line 6 from line 5. If zero or less, enter “-0-” . . . . . . . . . . . . . . . . 7 $8 Divide the amount on line 7 by $4,050 and enter the result here. Drop any fraction . . . . . . . 8

9 Enter the number from the Personal Allowances Worksheet, line H, page 1 . . . . . . . . . 9

10 Add lines 8 and 9 and enter the total here. If you plan to use the Two-Earners/Multiple Jobs Worksheet,

also enter this total on line 1 below. Otherwise, stop here and enter this total on Form W-4, line 5, page 1 10

Two-Earners/Multiple Jobs Worksheet (See Two earners or multiple jobs on page 1.)Note: Use this worksheet only if the instructions under line H on page 1 direct you here.1 Enter the number from line H, page 1 (or from line 10 above if you used the Deductions and Adjustments Worksheet) 1

2 Find the number in Table 1 below that applies to the LOWEST paying job and enter it here. However, if you are married filing jointly and wages from the highest paying job are $65,000 or less, do not enter 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 2016. For example, divide by 25 if you are paid every two

weeks and you complete this form on a date in January when there are 25 pay periods remaining in 2016. 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 - $6,000 06,001 - 14,000 1

14,001 - 25,000 225,001 - 27,000 327,001 - 35,000 435,001 - 44,000 544,001 - 55,000 655,001 - 65,000 765,001 - 75,000 875,001 - 80,000 980,001 - 100,000 10

100,001 - 115,000 11115,001 - 130,000 12130,001 - 140,000 13140,001 - 150,000 14 150,001 and over 15

All Others

If wages from LOWEST paying job are—

Enter on line 2 above

$0 - $9,000 09,001 - 17,000 1

17,001 - 26,000 226,001 - 34,000 334,001 - 44,000 444,001 - 75,000 575,001 - 85,000 685,001 - 110,000 7

110,001 - 125,000 8125,001 - 140,000 9140,001 and over 10

Table 2

Married Filing Jointly

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $75,000 $61075,001 - 135,000 1,010

135,001 - 205,000 1,130205,001 - 360,000 1,340360,001 - 405,000 1,420405,001 and over 1,600

All Others

If wages from HIGHEST paying job are—

Enter on line 7 above

$0 - $38,000 $61038,001 - 85,000 1,01085,001 - 185,000 1,130

185,001 - 400,000 1,340400,001 and over 1,600

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 are not required to provide the information requested on a form that is 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.

First name and middle initial Last name Your social security number

Permanent home address (number and street or rural route) Apartment number

City,village,orpostoffice State ZIPcode

Are you a resident of New York City? ........... Yes NoAre you a resident of Yonkers? ..................... Yes NoComplete the worksheet on page 3 before making any entries.1 TotalnumberofallowancesyouareclaimingforNewYorkStateandYonkers,ifapplicable(from line 17) ........... 12 Total number of allowances for New York City (from line 28) .................................................................................. 2

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 NewYorkStateamount ........................................................................................................................................ 34 New York City amount ........................................................................................................................................... 45 Yonkers amount .................................................................................................................................................... 5

Department of Taxation and Finance

Employee’s Withholding Allowance CertificateNew York State • New York City • Yonkers

SingleorHeadofhousehold Married

Married, but withhold at higher single rate

Note:Ifmarriedbutlegallyseparated,markanX in the Single or Head of household box.

IcertifythatIamentitledtothenumberofwithholdingallowancesclaimedonthiscertificate.Employee’s signature Date

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.) Employeridentificationnumber

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Changes effective for 2016FormIT-2104hasbeenrevisedfortaxyear2016.Theworksheetonpage3andthechartsbeginningonpage4,usedtocomputewithholdingallowancesortoenteranadditionaldollaramountonline(s)3,4,or5,havebeenrevised.IfyoupreviouslyfiledaFormIT-2104andusedtheworksheetorcharts,youshouldcompleteanew2016FormIT-2104andgive it to your employer.

Who should file this form Thiscertificate,FormIT-2104,iscompletedbyanemployeeandgiventotheemployertoinstructtheemployerhowmuchNewYorkState(andNew York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

IfyoudonotfileFormIT-2104,youremployermayusethesamenumberofallowancesyouclaimedonfederalFormW-4.Duetodifferencesintax law, this may result in the wrong amount of tax withheld for New York State,NewYorkCity,andYonkers.CompleteFormIT-2104eachyearandfileitwithyouremployerifthenumberofallowancesyoumayclaim

isdifferentfromfederalFormW-4orhaschanged.CommonreasonsforcompletinganewFormIT-2104eachyearincludethefollowing:• You started a new job.• You are no longer a dependent.• Your individual circumstances may have changed (for example, you

were married or have an additional child).• You moved into or out of NYC or Yonkers.• You itemize your deductions on your personal income tax return.• YouclaimallowancesforNewYorkStatecredits.• Youowedtaxorreceivedalargerefundwhenyoufiledyourpersonal

income tax return for the past year.• Yourwageshaveincreasedandyouexpecttoearn$106,950ormore

during the tax year.• Thetotalincomeofyouandyourspousehasincreasedto$106,950or

more for the tax year.• Youhavesignificantlymoreorlessincomefromothersourcesorfrom

another job.• You no longer qualify for exemption from withholding.

Instructions

Employer: Keep this certificate with your records.Mark an XinboxAand/orboxBtoindicatewhyyouaresendingacopyofthisformtoNewYorkState (see instructions):

A Employeeclaimedmorethan14exemptionallowancesforNYS ............ A

B Employee is a new hire or a rehire ... B First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Aredependenthealthinsurancebenefitsavailableforthisemployee? ............. Yes No

IfYes,enterthedatetheemployeequalifies(mm-dd-yyyy):

IT-2104

Page 2 of 7 IT-2104(2016)

• YouhavebeenadvisedbytheInternalRevenueServicethatyouare entitled to fewer allowances than claimed on your original federal FormW-4,andthedisallowedallowanceswereclaimedonyouroriginalFormIT-2104.

Exemption from withholdingYoucannotuseFormIT-2104toclaimexemptionfromwithholding.To claim exemption from income tax withholding, you mustfileFormIT-2104-E,Certificate of Exemption from Withholding, with your employer.Youmustfileanewcertificateeachyearthatyouqualifyforexemption. This exemption from withholding is allowable only if you had no New York income tax liability in the prior year, you expect none in the current year, andyouareover65yearsofage,under18,orafull-timestudentunder25.Youmayalsoclaimexemptionfromwithholdingifyou are a military spouse and meet the conditions set forth under the ServicemembersCivilReliefActasamendedbytheMilitarySpousesResidencyReliefAct.Ifyouareadependentwhoisunder18orafull-timestudent,youmayowetaxifyourincomeismorethan$3,100.

Withholding allowancesYou may not claim a withholding allowance for yourself or, if married, your spouse. Claim the number of withholding allowances you compute inPart1andPart3onpage3ofthisform.Ifyouwantmoretaxwithheld, you may claim fewer allowances. If you claim more than 14 allowances, your employer must send a copy of your Form IT-2104 totheNewYorkStateTaxDepartment.Youmaythenbeaskedtoverifyyourallowances.Ifyouarriveatnegativeallowances(lessthanzero)onlines1or2andyouremployercannotaccommodatenegativeallowances, enter 0 and see Additional dollar amount(s) below.

Income from sources other than wages –Ifyouhavemorethan$1,000ofincomefromsourcesotherthanwages(suchasinterest,dividends, or alimony received), reduce the number of allowances claimedonline1andline2(ifapplicable)oftheIT-2104certificatebyoneforeach$1,000ofnonwageincome.Ifyouarriveatnegativeallowances(less than zero), see Withholding allowances above. You may also considerfilingestimatedtax,especiallyifyouhavesignificantamountsof nonwage income. Estimated tax requires that payments be made by the employee directly to the Tax Department on a quarterly basis. For moreinformation,seetheinstructionsforFormIT-2105,Estimated Tax Payment Voucher for Individuals, or see Need help?onpage6.

Other credits (Worksheetline13) – Ifyouwillbeeligibletoclaimany credits other than the credits listed in the worksheet, such as an investment tax credit, you may claim additional allowances.

FindyourfilingstatusandyourNewYorkadjustedgrossincome(NYAGI)in the chart below, and divide the amount of the expected credit by the number indicated. Enter the result (rounded to the nearest whole number) online13.

Example: You are married and expect your New York adjusted gross income to be less than $321,050. In addition, you expect to receive a flow-through of an investment tax credit from the S corporation of which you are a shareholder. The investment tax credit will be $160. Divide the expected credit by 66. 160/66 = 2.4242. The additional withholding allowance(s) would be 2. Enter 2 on line 13.

Married couples with both spouses working –Ifyouandyourspousebothwork,youshouldeachfileaseparateIT-2104certificatewithyourrespective employers. Your withholding will better match your total tax if thehigherwage-earningspouseclaimsallofthecouple’sallowancesandthelowerwage-earningspouseclaimszeroallowances.Do not claim moretotalallowancesthanyouareentitledto.Ifyourcombinedwagesare:• lessthan$106,950,youshouldeachmarkanX in the box Married,

but withhold at higher single rateonthecertificatefront,anddividethe

totalnumberofallowancesthatyoucomputeonline17andline28(ifapplicable) between you and your working spouse.

• $106,950ormore,usethechart(s)inPart4andentertheadditionalwithholding dollar amount on line 3.

Taxpayers with more than one job –Ifyouhavemorethanonejob,fileaseparateIT-2104certificatewitheachofyouremployers.Besure to claim only the total number of allowances that you are entitled to. Your withholding will better match your total tax if you claim all of yourallowancesatyourhigher-payingjobandzeroallowancesatthelower-payingjob.Inaddition,tomakesurethatyouhaveenoughtax withheld, if you are a single taxpayer or head of household with two or more jobs, and your combined wages from all jobs are under $106,950,reducethenumberofallowancesbysevenonline1andline2(ifapplicable)onthecertificateyoufilewithyourhigher-payingjobemployer.Ifyouarriveatnegativeallowances(lessthanzero),see Withholding allowances above.

Ifyouareasingleoraheadofhouseholdtaxpayer,andyourcombinedwagesfromallofyourjobsarebetween$106,950and$2,248,076,usethe chart(s) in Part 5 and enter the additional withholding dollar amount from the chart on line 3.

Ifyouareamarriedtaxpayer,andyourcombinedwagesfromallofyourjobsare$106,950ormore,usethechart(s)inPart4andentertheadditionalwithholdingdollaramountfromthechartonline3(Substitutethe words Higher-paying job for Higher earner’s wages within the chart).

Dependents – Ifyouareadependentofanothertaxpayerandexpectyourincometoexceed$3,100,youshouldreduceyourwithholdingallowancesbyoneforeach$1,000ofincomeover$2,500.Thiswillensure that your employer withholds enough tax.

Following the above instructions will help to ensure that you will not owe additionaltaxwhenyoufileyourreturn.

Heads of households with only one job – Ifyouwillusethehead-of-householdfilingstatusonyourstateincometaxreturn,markthe Single or Head of householdboxonthefrontofthecertificate.Ifyouhave only one job, you may also wish to claim two additional withholding allowancesonline14.

Additional dollar amount(s)You may ask your employer to withhold an additional dollar amount each payperiodbycompletinglines3,4,and5onFormIT-2104.Inmostinstances, if you compute a negative number of allowances and your employer cannot accommodate a negative number, for each negative allowanceclaimedyoushouldhaveanadditional$1.85oftaxwithheldperweekforNewYorkStatewithholdingonline3,andanadditional$0.80oftaxwithheldperweekforNewYorkCitywithholdingonline4.Yonkersresidentsshoulduse16.75%(.1675)oftheNewYorkStateamountforadditional withholding for Yonkers on line 5.

Note:Ifyouarerequestingyouremployertowithholdanadditionaldollaramountonlines3,4,or5ofthisallowancecertificate,theadditionaldollar amount, as determined by these instructions or by using the chart(s)inPart4orPart5,isaccurateforaweeklypayroll.Therefore,if you are not paid on a weekly basis, you will need to adjust the dollar amount(s) that you compute. For example, if you are paid biweekly, you must double the dollar amount(s) computed.

Avoid underwithholdingFormIT-2104,togetherwithyouremployer’swithholdingtables,isdesigned to ensure that the correct amount of tax is withheld from your pay. Ifyoufailtohaveenoughtaxwithheldduringtheentireyear,youmayowealargetaxliabilitywhenyoufileyourreturn.TheTaxDepartmentmustassess interest and may impose penalties in certain situations in addition tothetaxliability.Evenifyoudonotfileareturn,wemaydeterminethat you owe personal income tax, and we may assess interest and penalties on the amount of tax that you should have paid during the year.

Single and NYAGI is:

Head of household and NYAGI is:

Married and NYAGI is:

Divide amount of expected credit by:

Less than Less than Less than 66 $214,000 $267,500 $321,050 Between Between Between $214,000and $267,500and $321,050and 68 $1,070,350 $1,605,650 $2,140,900 Over Over Over 88 $1,070,350 $1,605,650 $2,140,900

(continued)

IT-2104 (2016) Page 3 of 7

WorksheetSee the instructions before completing this worksheet.

Part 1 – Complete this part to compute your withholding allowances for New York State and Yonkers (line1).

Part 3 – Complete this part to compute your withholding allowances for New York City (line2).

Part 2 – Complete this part only if you expect to itemize deductions on your state return.

18 Enter your estimated federal itemized deductions for the tax year ........................................................................................... 18 19 Enteryourestimatedstate,local,andforeignincometaxesorstateandlocalgeneralsalestaxesincludedonline18 ........ 19 20 Subtractline19fromline18 .................................................................................................................................................... 20 21 Enter your estimated college tuition itemized deduction .......................................................................................................... 21 22 Addlines20and21 ................................................................................................................................................................. 22 23 Basedonyourfederalfilingstatus,entertheapplicableamountfromthetablebelow ........................................................... 23

Single(cannotbeclaimedasadependent) .... $ 7,950 Qualifyingwidow(er) ........................................ $15,950 Single(canbeclaimedasadependent) ....... $ 3,100 Marriedfilingjointly .......................................... $15,950 Headofhousehold......................................... $11,150 Marriedfilingseparatereturns ......................... $ 7,950

24 Subtractline23fromline22(if line 23 is larger than line 22, enter 0 here and on line 16 above) ....................................................... 24 25 Divideline24by$1,000.Dropanyfractionandentertheresulthereandonline16above ................................................... 25

26 Entertheamountfromline6above ......................................................................................................................................... 26 27 Addlines14through16aboveandentertotalhere ................................................................................................................ 27 28 Addlines26and27.Entertheresulthereandonline2 ......................................................................................................... 28

6 Enter the number of dependents that you will claim on your state return (do not include yourself or, if married, your spouse) ..... 6 For lines 7, 8, and 9, enter 1 for each credit you expect to claim on your state return. 7 College tuition credit .................................................................................................................................................................. 7 8 NewYorkStatehouseholdcredit ............................................................................................................................................... 8 9 Realpropertytaxcredit .............................................................................................................................................................. 9 For lines 10, 11, and 12, enter 3 for each credit you expect to claim on your state return. 10 Child and dependent care credit ................................................................................................................................................ 10 11 Earned income credit ................................................................................................................................................................. 11 12 EmpireStatechildcredit ............................................................................................................................................................ 12 13 Other credits (see instructions) ...................................................................................................................................................... 13 14 Headofhouseholdstatusand only one job (enter 2 if the situation applies) ................................................................................... 14 15 Enter an estimate of your federal adjustments to income, such as alimony you will pay for the tax year anddeductibleIRAcontributionsyouwillmakeforthetaxyear.Totalestimate$ . Dividethisestimateby$1,000.Dropanyfractionandenterthenumber .............................................................................. 15 16 Ifyouexpecttoitemizedeductionsonyourstatetaxreturn,completePart2belowandenterthenumberfromline25. All others enter 0 ................................................................................................................................................................... 16 17 Addlines6through16.Entertheresulthereandonline1.Ifyouhavemorethanonejob,orifyouandyourspouseboth work, see instructions for Taxpayers with more than one job or Married couples with both spouses working. ..................... 17

Standard deduction table

EmployersBox A – Ifyouarerequiredtosubmitacopyofanemployee’sFormIT-2104totheTaxDepartmentbecausetheemployeeclaimedmorethan14allowances,markanX in box A and send a copy ofFormIT-2104to:NYS Tax Department, Income Tax Audit Administrator, Withholding Certificate Coordinator, W A Harriman Campus, Albany NY 12227-0865.Iftheemployeeisalsoanewhireorrehire, see Box Binstructions.SeePublication55,Designated Private Delivery Services,ifnotusingU.S.Mail.

Duedatesforsendingcertificatesreceivedfromemployeesclaimingmorethan14allowancesare:Quarter Due date Quarter Due dateJanuary–March April30 July–September October31April–June July31 October–December January31

Box B – IfyouaresubmittingacopyofthisformtocomplywithNewYorkState’sNewHireReportingProgram,markanX in box B. Enter the firstdayanyservicesareperformedforwhichtheemployeewillbepaidwages, commissions, tips and any other type of compensation. For servicesbasedsolelyoncommissions,thisisthefirstdayanemployeeworking for commissions is eligible to earn commissions. Also, mark an X in the Yes or Noboxindicatingifdependenthealthinsurancebenefitsareavailabletothisemployee.IfYes,enterthedatetheemployeequalifiesforcoverage.Mailthecompletedform,within20daysofhiring,to:NYS Tax Department, New Hire Notification, PO Box 15119, Albany NY 12212-5119. Toreportnewly-hiredorrehiredemployeesonlineinsteadofsubmitting this form, go to www.nynewhire.com.

Page 4 of 7 IT-2104 (2016)

Part 4 – These charts are only for married couples with both spouses working or married couples with one spouse working more than onejob,andwhosecombinedwagesarebetween$106,950and$2,248,076.

Enter the additional withholding dollar amount on line 3.

Theadditionaldollaramount,asshownbelow,isaccurateforaweeklypayroll.Ifyouarenotpaidonaweeklybasis,youwillneedtoadjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.

Combined wages between $106,950 and $535,149Higher earner’s wages

Combined wages between $535,150 and $1,177,449

Higher earner’s wages

$106,950 $128,400 $149,750 $171,150 $192,550 $235,400 $278,250 $321,050 $374,600 $428,100 $481,650 $128,399 $149,749 $171,149 $192,549 $235,399 $278,249 $321,049 $374,599 $428,099 $481,649 $535,149

$53,450 $74,799 $12 $16

$74,800 $96,199 $11 $17 $22 $27

$96,200 $117,649 $8 $15 $20 $27 $35

$117,650 $128,399 $2 $10 $16 $23 $32 $31

$128,400 $139,099 $4 $13 $20 $30 $29

$139,100 $149,749 $2 $10 $17 $27 $29 $26

$149,750 $160,499 $4 $15 $25 $29 $24

$160,500 $171,349 $2 $11 $22 $27 $24 $22

$171,350 $192,549 $4 $17 $22 $23 $22 $18

$192,550 $235,399 $6 $12 $18 $20 $19 $19

$235,400 $278,249 $6 $12 $23 $25 $19 $18

$278,250 $321,049 $6 $18 $30 $26 $19

$321,050 $374,599 $10 $20 $27 $22

$374,600 $428,099 $8 $16 $23

$428,100 $481,649 $8 $16

$481,650 $535,149 $8

$535,150 $588,700 $642,200 $695,700 $749,250 $802,800 $856,300 $909,850 $963,400 $1,016,900 $1,070,350 $1,123,950 $588,699 $642,199 $695,699 $749,249 $802,799 $856,299 $909,849 $963,399 $1,016,899 $1,070,349 $1,123,949 $1,177,449

$235,400 $278,249 $18

$278,250 $321,049 $20 $16

$321,050 $374,599 $15 $17 $19 $14

$374,600 $428,099 $18 $11 $13 $15 $7 $7

$428,100 $481,649 $23 $18 $11 $13 $15 $7 $7 $7

$481,650 $535,149 $16 $23 $18 $11 $13 $15 $7 $7 $7 $7

$535,150 $588,699 $8 $16 $23 $18 $11 $13 $15 $7 $7 $7 $8 $11

$588,700 $642,199 $8 $16 $23 $18 $11 $13 $15 $7 $7 $8 $11

$642,200 $695,699 $8 $16 $23 $18 $11 $13 $15 $7 $8 $11

$695,700 $749,249 $8 $16 $23 $18 $11 $13 $15 $8 $11

$749,250 $802,799 $8 $16 $23 $18 $11 $13 $16 $11

$802,800 $856,299 $8 $16 $23 $18 $11 $14 $19

$856,300 $909,849 $8 $16 $23 $18 $12 $17

$909,850 $963,399 $8 $16 $23 $20 $15

$963,400 $1,016,899 $8 $16 $24 $23

$1,016,900 $1,070,349 $8 $17 $27

$1,070,350 $1,123,949 $9 $19

$1,123,950 $1,177,449 $9

IT-2104 (2016) Page 5 of 7

Combined wages between $1,177,450 and $1,712,749

Higher earner’s wages

Combined wages between $1,712,750 and $2,248,076

Higher earner’s wages

Note:Thesechartsdonotaccountforadditionalwithholdinginthefollowinginstances: • amarriedcouplewithbothspousesworking,whereonespouse’swagesaremorethan$1,124,038butlessthan$2,248,076,andtheother

spouse’swagesarealsomorethan$1,124,038butlessthan$2,248,076; • marriedtaxpayerswithonlyonespouseworking,andthatspouseworksmorethanonejob,withwagesfromeachjobunder$2,248,076,but

combinedwagesfromalljobsisover$2,248,076.Ifyouareinoneofthesesituationsandyouwouldliketorequestanadditionaldollaramountofwithholdingfromyourwages,pleasecontacttheTax

Department for assistance (see Need help?onpage6).

$1,177,450 $1,230,950 $1,284,550 $1,338,050 $1,391,550 $1,445,100 $1,498,600 $1,552,100 $1,605,650 $1,659,200 $1,230,949 $1,284,549 $1,338,049 $1,391,549 $1,445,099 $1,498,599 $1,552,099 $1,605,649 $1,659,199 $1,712,749

$588,700 $642,199 $14 $17

$642,200 $695,699 $14 $17 $21 $24

$695,700 $749,249 $14 $17 $21 $24 $27 $30

$749,250 $802,799 $14 $17 $21 $24 $27 $30 $33 $36

$802,800 $856,299 $14 $17 $21 $24 $27 $30 $33 $36 $39 $42

$856,300 $909,849 $23 $17 $21 $24 $27 $30 $33 $36 $39 $42

$909,850 $963,399 $21 $26 $21 $24 $27 $30 $33 $36 $39 $42

$963,400 $1,016,899 $18 $24 $29 $24 $27 $30 $33 $36 $39 $42

$1,016,900 $1,070,349 $26 $22 $27 $32 $27 $30 $33 $36 $39 $42

$1,070,350 $1,123,949 $29 $27 $23 $28 $33 $28 $31 $34 $37 $41

$1,123,950 $1,177,449 $19 $29 $27 $23 $28 $33 $28 $31 $34 $37

$1,177,450 $1,230,949 $9 $19 $29 $27 $23 $28 $33 $28 $31 $34

$1,230,950 $1,284,549 $9 $19 $29 $27 $23 $28 $33 $28 $31

$1,284,550 $1,338,049 $9 $19 $29 $27 $23 $28 $33 $28

$1,338,050 $1,391,549 $9 $19 $29 $27 $23 $28 $33

$1,391,550 $1,445,099 $9 $19 $29 $27 $23 $28

$1,445,100 $1,498,599 $9 $19 $29 $27 $23

$1,498,600 $1,552,099 $9 $19 $29 $28

$1,552,100 $1,605,649 $9 $19 $29

$1,605,650 $1,659,199 $9 $19

$1,659,200 $1,712,749 $9

$1,712,750 $1,766,250 $1,819,800 $1,873,300 $1,926,800 $1,980,350 $2,033,900 $2,087,400 $2,140,900 $2,194,500 $1,766,249 $1,819,799 $1,873,299 $1,926,799 $1,980,349 $2,033,899 $2,087,399 $2,140,899 $2,194,499 $2,248,076

$856,300 $909,849 $45 $48

$909,850 $963,399 $45 $48 $51 $54

$963,400 $1,016,899 $45 $48 $51 $54 $58 $61

$1,016,900 $1,070,349 $45 $48 $51 $54 $58 $61 $64 $67

$1,070,350 $1,123,949 $44 $47 $50 $53 $56 $59 $62 $65 $484 $911

$1,123,950 $1,177,449 $41 $44 $47 $50 $53 $56 $59 $62 $481 $911

$1,177,450 $1,230,949 $37 $41 $44 $47 $50 $53 $56 $59 $478 $908

$1,230,950 $1,284,549 $34 $37 $41 $44 $47 $50 $53 $56 $475 $905

$1,284,550 $1,338,049 $31 $34 $37 $41 $44 $47 $50 $53 $472 $902

$1,338,050 $1,391,549 $28 $31 $34 $38 $41 $44 $47 $50 $468 $899

$1,391,550 $1,445,099 $33 $28 $31 $34 $37 $41 $44 $47 $465 $896

$1,445,100 $1,498,599 $28 $33 $28 $31 $34 $37 $41 $44 $462 $893

$1,498,600 $1,552,099 $23 $28 $33 $28 $31 $34 $37 $41 $459 $889

$1,552,100 $1,605,649 $27 $23 $28 $33 $28 $31 $34 $37 $456 $886

$1,605,650 $1,659,199 $29 $27 $23 $28 $33 $28 $31 $34 $453 $883

$1,659,200 $1,712,749 $19 $29 $27 $23 $28 $33 $28 $31 $450 $880

$1,712,750 $1,766,249 $9 $19 $29 $27 $23 $28 $33 $28 $447 $877

$1,766,250 $1,819,799 $9 $19 $29 $27 $23 $28 $33 $444 $874

$1,819,800 $1,873,299 $9 $19 $29 $27 $23 $28 $449 $871

$1,873,300 $1,926,799 $9 $19 $29 $27 $23 $444 $876

$1,926,800 $1,980,349 $9 $19 $29 $27 $439 $871

$1,980,350 $2,033,899 $9 $19 $29 $443 $866

$2,033,900 $2,087,399 $9 $19 $444 $870

$2,087,400 $2,140,899 $9 $434 $871

$2,140,900 $2,194,499 $218 $446

$2,194,500 $2,248,076 $14

Need help?

Telephone assistanceAutomatedincometaxrefundstatus: (518)457-5149Personal Income TaxInformationCenter: (518)457-5181Toorderformsandpublications: (518)457-5431Text Telephone (TTY) Hotline (for persons with hearing and speech disabilities using a TTY): (518)485-5082

Visit our Web site at www.tax.ny.gov• get information and manage your taxes online• check for new online services and features

Page 6 of 7 IT-2104 (2016)

Combined wages between $106,950 and $535,149Higher wage

$535,150 $588,700 $642,200 $695,700 $749,250 $802,800 $856,300 $909,850 $963,400 $1,016,900 $1,070,350 $1,123,950 $588,699 $642,199 $695,699 $749,249 $802,799 $856,299 $909,849 $963,399 $1,016,899 $1,070,349 $1,123,949 $1,177,449

$235,400 $278,249 $9

$278,250 $321,049 $9 $8

$321,050 $374,599 $17 $8 $8 $8

$374,600 $428,099 $15 $17 $8 $8 $8 $8

$428,100 $481,649 $22 $15 $17 $8 $8 $8 $8 $8

$481,650 $535,149 $16 $22 $15 $17 $8 $8 $8 $8 $8 $8

$535,150 $588,699 $8 $16 $22 $15 $17 $8 $8 $8 $8 $8 $224 $450

$588,700 $642,199 $8 $16 $22 $15 $17 $8 $8 $8 $8 $224 $450

$642,200 $695,699 $8 $16 $22 $15 $17 $8 $8 $8 $224 $450

$695,700 $749,249 $8 $16 $22 $15 $17 $8 $8 $224 $450

$749,250 $802,799 $8 $16 $22 $15 $17 $8 $224 $450

$802,800 $856,299 $8 $16 $22 $15 $17 $224 $450

$856,300 $909,849 $8 $16 $22 $15 $232 $450

$909,850 $963,399 $8 $16 $22 $230 $458

$963,400 $1,016,899 $8 $16 $237 $456

$1,016,900 $1,070,349 $8 $231 $463

$1,070,350 $1,123,949 $115 $242

$1,123,950 $1,177,449 $14

Combined wages between $535,150 and $1,177,449

Higher wage

Part 5 – These charts are only for single taxpayers and head of household taxpayers with more than one job, and whose combined wagesarebetween$106,950and$2,248,076.

Enter the additional withholding dollar amount on line 3.

Theadditionaldollaramount,asshownbelow,isaccurateforaweeklypayroll.Ifyouarenotpaidonaweeklybasis,youwillneedtoadjust these dollar amount(s). For example, if you are paid biweekly, you must double the dollar amount(s) computed.

(Part 5 continued on page 7)

$106,950 $128,400 $149,750 $171,150 $192,550 $235,400 $278,250 $321,050 $374,600 $428,100 $481,650 $128,399 $149,749 $171,149 $192,549 $235,399 $278,249 $321,049 $374,599 $428,099 $481,649 $535,149

$53,450 $74,799 $13 $18

$74,800 $96,199 $13 $19 $26 $25

$96,200 $117,649 $8 $17 $23 $26 $27

$117,650 $128,399 $2 $11 $18 $21 $25 $28

$128,400 $139,099 $4 $15 $18 $22 $28

$139,100 $149,749 $2 $11 $14 $19 $28 $26

$149,750 $160,499 $4 $11 $15 $28 $24

$160,500 $171,349 $2 $8 $13 $27 $25 $21

$171,350 $192,549 $3 $11 $25 $28 $22 $24

$192,550 $235,399 $8 $20 $29 $26 $24 $18

$235,400 $278,249 $8 $16 $23 $18 $18 $12

$278,250 $321,049 $7 $15 $22 $15 $16

$321,050 $374,599 $8 $16 $22 $15

$374,600 $428,099 $8 $16 $22

$428,100 $481,649 $8 $16

$481,650 $535,149 $8

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IT-2104 (2016) Page 7 of 7

$1,177,450 $1,230,950 $1,284,550 $1,338,050 $1,391,550 $1,445,100 $1,498,600 $1,552,100 $1,605,650 $1,659,200 $1,230,949 $1,284,549 $1,338,049 $1,391,549 $1,445,099 $1,498,599 $1,552,099 $1,605,649 $1,659,199 $1,712,749

$588,700 $642,199 $473 $496

$642,200 $695,699 $473 $496 $520 $543

$695,700 $749,249 $473 $496 $520 $543 $566 $590

$749,250 $802,799 $473 $496 $520 $543 $566 $590 $613 $637

$802,800 $856,299 $473 $496 $520 $543 $566 $590 $613 $637 $660 $683

$856,300 $909,849 $473 $496 $520 $543 $566 $590 $613 $637 $660 $683

$909,850 $963,399 $473 $496 $520 $543 $566 $590 $613 $637 $660 $683

$963,400 $1,016,899 $481 $496 $520 $543 $566 $590 $613 $637 $660 $683

$1,016,900 $1,070,349 $479 $505 $520 $543 $566 $590 $613 $637 $660 $683

$1,070,350 $1,123,949 $271 $287 $313 $328 $351 $375 $398 $421 $445 $468

$1,123,950 $1,177,449 $39 $69 $85 $110 $125 $149 $172 $195 $219 $242

$1,177,450 $1,230,949 $14 $39 $69 $85 $110 $125 $149 $172 $195 $219

$1,230,950 $1,284,549 $14 $39 $69 $85 $110 $125 $149 $172 $195

$1,284,550 $1,338,049 $14 $39 $69 $85 $110 $125 $149 $172

$1,338,050 $1,391,549 $14 $39 $69 $85 $110 $125 $149

$1,391,550 $1,445,099 $14 $39 $69 $85 $110 $125

$1,445,100 $1,498,599 $14 $39 $69 $85 $110

$1,498,600 $1,552,099 $14 $39 $69 $85

$1,552,100 $1,605,649 $14 $39 $69

$1,605,650 $1,659,199 $14 $39

$1,659,200 $1,712,749 $14

Combined wages between $1,177,450 and $1,712,749

Higher wage

$1,712,750 $1,766,250 $1,819,800 $1,873,300 $1,926,800 $1,980,350 $2,033,900 $2,087,400 $2,140,900 $2,194,500 $1,766,249 $1,819,799 $1,873,299 $1,926,799 $1,980,349 $2,033,899 $2,087,399 $2,140,899 $2,194,499 $2,248,076

$856,300 $909,849 $707 $730

$909,850 $963,399 $707 $730 $753 $777

$963,400 $1,016,899 $707 $730 $753 $777 $800 $823

$1,016,900 $1,070,349 $707 $730 $753 $777 $800 $823 $847 $870

$1,070,350 $1,123,949 $491 $515 $538 $562 $585 $608 $632 $655 $678 $272

$1,123,950 $1,177,449 $265 $289 $312 $336 $359 $382 $406 $429 $452 $474

$1,177,450 $1,230,949 $242 $265 $289 $312 $335 $359 $382 $406 $429 $452

$1,230,950 $1,284,549 $219 $242 $265 $289 $312 $335 $359 $382 $406 $429

$1,284,550 $1,338,049 $195 $219 $242 $265 $289 $312 $336 $359 $382 $406

$1,338,050 $1,391,549 $172 $195 $219 $242 $265 $289 $312 $335 $359 $382

$1,391,550 $1,445,099 $149 $172 $195 $219 $242 $265 $289 $312 $335 $359

$1,445,100 $1,498,599 $125 $149 $172 $195 $219 $242 $265 $289 $312 $335

$1,498,600 $1,552,099 $110 $125 $149 $172 $195 $219 $242 $265 $289 $312

$1,552,100 $1,605,649 $85 $110 $125 $149 $172 $195 $219 $242 $265 $289

$1,605,650 $1,659,199 $69 $85 $110 $125 $149 $172 $195 $219 $242 $265

$1,659,200 $1,712,749 $39 $69 $85 $110 $125 $149 $172 $195 $219 $242

$1,712,750 $1,766,249 $14 $39 $69 $85 $110 $125 $149 $172 $195 $219

$1,766,250 $1,819,799 $14 $39 $69 $85 $110 $125 $149 $172 $195

$1,819,800 $1,873,299 $14 $39 $69 $85 $110 $125 $149 $172

$1,873,300 $1,926,799 $14 $39 $69 $85 $110 $125 $149

$1,926,800 $1,980,349 $14 $39 $69 $85 $110 $125

$1,980,350 $2,033,899 $14 $39 $69 $85 $110

$2,033,900 $2,087,399 $14 $39 $69 $85

$2,087,400 $2,140,899 $14 $39 $69

$2,140,900 $2,194,499 $14 $39

$2,194,500 $2,248,076 $14

Combined wages between $1,712,750 and $2,248,076

Higher wage

Direct Deposit Form  

Please bring a voided check or have your bank 

representative fill out the middle portion of this form 

prior to the Human Resources orientation. 

 If you have a joint account please have both parties 

sign.  

Thank you 

AC 2772 (Rev. 8/07) PLEASE SEE REVERSE SIDE FOR INSTRUCTIONS

Direct Deposit Form for NYS Employees

(To be used for enrollment, changes and cancellations)

Section A: Employee Information

NAME (LAST, FIRST, MI) ________________________________________________ WORK PHONE # ( ) ____________

LAST FOUR DIGITS OF SOCIAL SECURITY # __ __ __ __ AGENCY/DEPT CODE __ __ __ __ __

For more than three accounts or if you prefer to list each Financial Institution on a separate form, use additional forms as necessary. Up to seven fixed amount or percentage deposits may be processed as well as one excess (net pay) deposit.

Section B: Account Type New or Additional *

( )

Change Joint

Account Holder *

( )

Change Amount or Percentage

( )

Cancel

( )

Name of Financial Institution

Account Number Amount, Percentage or

Excess

1. Savings Checking

2. Savings Checking

3. Savings Checking

*For new/additional accounts with joint account holders or to add a joint account holder to existing accounts, both signatures are required in Section D.

Section C: This section must be completed by your financial institution for new/additional accounts when directing funds into a savings account or into a checking account if a voided personal check is not attached. The employee’s name MUST appear on the account(s). As a representative of the below named financial institution, I certify that this institution is ACH capable and agree to receive and deposit the salary to the account shown above in accordance with Part 102 of the Codes, Rules, and Regulations of the State of New York and to be bound by such rules. Salary credited to the account below will be available to the depositor on payday.

1. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type Savings Checking

Depositor’s Account Number (EFT Format) Routing Number ________________________________________________________ __ __ __ __ __ __ __ __ __

Print or Type Representative’s Name

Signature of Representative Telephone Number Date

2. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type Savings Checking

Depositor’s Account Number (EFT Format) Routing Number ________________________________________________________ __ __ __ __ __ __ __ __ __

Print or Type Representative’s Name Signature of Representative Telephone Number Date

3. NAME OF FINANCIAL INSTITUTION __________________________________________ Account Type Savings Checking

Depositor’s Account Number (EFT Format) Routing Number ________________________________________________________ __ __ __ __ __ __ __ __ __

Print or Type Representative’s Name Signature of Representative Telephone Number Date

Section D: Employee/Joint Account Holders Certification: I certify that I read and understand the instructions to this form, including the authorization for recovery. In signing this form, I authorize my salary payment to be sent to the designated financial institution(s) to be deposited into the specified account(s). The joint account holder for accounts listed in Section B, if any, must sign on the corresponding line for new/additional accounts or account holder(s).

Employee Signature___________________________________________________________________________ Date __________________

B-1 Joint Account Holder ___________________________________________________________________________ Date ____________________

B-2 Joint Account Holder ___________________________________________________________________________ Date ____________________

B-3 Joint Account Holder ___________________________________________________________________________ Date ____________________

INSTRUCTIONS: Please complete the form as described below, and then forward it to your agency/department payroll or personnel office. You can also contact that office for assistance in completing the form. NEW/ADDITIONAL ACCOUNT OR CHANGES IN ACCOUNT HOLDERS: Employee must complete Sections A, B, and D for each new/additional account or for changes in account holders. See instructions below for Section C. Section A: Indicate your name, work phone number and Agency/Department code. For your personal privacy, enter only the last four digits of your social security number. Section B: To enroll in direct deposit or add an account, place a check mark in the account type (checking or savings) and in the “New or Additional” column. For changes in account holders, place a check mark in the account type and in the appropriate “Change” column. Indicate the name of the financial institution, account number, and amount or percentage to be deposited.

Employees may choose up to seven fixed amount or percentage deposits, as well as one excess (net pay) deposit. This form accommodates up to three accounts. For more than three accounts or if you prefer to list each financial institution on a separate form, use additional forms as necessary.

Account number is obtained from a personal check, bank statement, or the financial institution. To deposit a fixed amount, enter a specific amount (may include cents, e.g. $100.25). To deposit a portion of

the paycheck, enter a specific percent (must be a full percentage, e.g. 50%). Write the word “excess” to deposit the remainder of monies after all other distributions.

Section C: For Savings Accounts, this section must be completed by your financial institution(s). For Checking Accounts, this section must be completed by your financial institution(s) if you are not attaching a voided personal check. The employee’s name must appear on the account. Section D: The Employee/Joint Account Holder Certification must be signed by the employee in all instances and any joint account holder if this is a new/added account. By signing this form, the employee and any joint account holder each allows the State, through the financial institution, to debit the account in order to recover any salary to which the employee was not entitled or that was deposited to the account in error. This means of recovery shall not prevent the State from utilizing any other lawful means to retrieve salary payments to which the employee is not entitled. CHANGES TO MONEY OR PERCENTAGE AMOUNT: Employees may add, change or cancel the money or percentage amount deposited to an account by completing Sections A, B, and D of a new Direct Deposit Form. Section C does not need to be completed for these changes. In Section B, place a check mark in the appropriate “Change” column. New fixed amount or percentage direct deposits will be assigned a lesser priority than existing fixed amount or percentage direct deposits. For example, if an employee’s pay is not sufficient to cover all direct deposits, the most recently designated direct deposit(s) will not be taken. To change direct deposit priorities, please contact your agency payroll or personnel office. Financial institution changes may take up to two payroll periods to become effective. Employees should maintain accounts canceled and replaced by new accounts until the new transaction is complete. If canceled accounts are not temporarily maintained until the new account receives the employee’s direct deposit transaction, employees may experience a delay in payments. Joint account holder’s signature is not required for these transactions. CANCELLATIONS: The agreement represented by this authorization will remain in effect until canceled by the employee, the financial institution, or the State agency. To cancel the agreement, the employee must complete Sections A, B and D of a new Direct Deposit Form for the transaction(s) to be canceled. Joint account holder’s signature is not required. The financial institution may cancel the agreement by providing the employee and the State agency with a written notice 30 days in advance of the cancellation date. The financial institution cannot cancel the authorization without notification to both the employee and the State agency. The State agency may cancel an employee’s direct deposits when internal control policies would be compromised by this form of salary payment. NOTE: Direct deposit advice statements are distributed by the enrollee’s agency. If the statement is unclaimed, it will be held by the agency for thirty (30) days after which time the statement will be destroyed.

Additional Information

The information on this form is required pursuant to Part 102 of the Codes, Rules and Regulations of New York State (2 NYCRR 102). This form is a legal document and cannot be altered by the agency, employee or financial institution. If there are any changes, the employee must complete a new form. The information supplied by the employee will be provided only to the designated financial institution(s) and/or their agent(s) for the purpose of processing payments. Failure by the employee to provide the requested information may delay or prevent the receipt of payments through the Direct Deposit/Electronic Funds Transfer Program of the Bureau of State Payroll Services, NYS Office of the State Comptroller.

THE GRADUATE CENTER OFFICE OF HUMAN RESOURCES PERSONNEL DATA SURVEY

LAST NAME: FIRST NAME: MIDDLE INITIAL: S.S.#:

DEPT./PROGRAM: WORKSITE ADDRESS: START DATE:

HOME TEL#: Email: PLEASE CHECK THE APPROPRIATE TITLE

INSTRUCTIONAL TITLESAdjunct Prof. ___________________Adjunct Assoc. Prof. ____________Adjunct Asst. Prof. ______________Adjunct Lecturer ________________Assoc. Prof. ____________________Asst. Prof. ______________________Asst. to HEO ____________________Chief College Lab. Tech. __________College Lab. Technician __________College Security Dir. ______________Cont. Ed. Teacher (H) _____________Cont. Ed. Teacher (credit) __________Dist. Prof. ________________________Higher Education Officer ___________Higher Education Assoc. ___________Higher Education Asst. ____________Non-Teaching Adjunct* ____________ Professor ________________________

Sr. College Lab. Tech. _____________Visiting Prof. _____________________Visiting Assoc. Prof. ______________Visiting Asst. Prof. _________________Grad. Asst. A ______________________Grad. Asst. B_______________________Grad. Asst. C_______________________Grad. Asst. D _______________________.......................................................

*Lect. 04689, Instructor 04688, Asst. Prof. 04687, Assoc. Prof. 04686, Prof. 04685, CLT 04601

NON-INSTRUCTIONAL TITLESCamp. Peace Off. L I/III ______________Campus Sec. Asst. __________________College Accountant ________________College Accounting Asst. ____________College Assistant __________________College Graphic Designer ___________Coll. Print Shop Coord. ______________

Coll. Print Shop Asst. _____________Coll. Print Shop Assoc. ____________CUNY Admin. Asst. _______________CUNY Computer Aide _____________CUNY Office Asst. ________________CUNY Comp. Spec./ ________________Software IT Assistant ** _____________________IT Associate ** ____________________IT Senior Associate ** ______________IT Support Assistant ** _____________Mail Messenger Svc. Wrk. ___________Purchasing Agent _________________Pub. Safety Sgt. _________________Other** - (Please specify) ________________________________**If hourly, please indicate “H”

CIVIL SERVICE MANAGERIALAsst. College Security Dir. ____________Chief Admin. Supt. _________________College Sec. Dir. ___________________Computer Systems Mgr. _____________

EXECUTIVE COMPENSATION PLANAdministrator _____________________Asst. Administrator ________________Asst. Vice President ________________Assoc. Administrator _______________Dean _____________________________President _________________________Sr. Vice President __________________Vice President _____________________Other (Please specify) __________________________________

Degree(s) Earned:

Highest Degree/Diploma Earned: Year Conferred: Institution Name & Address where earned: Type of Institution: Public Private 2 Yr. 4 Yr. Major Field of Study/Discipline:

Other Degree Earned: Year Conferred: Institution Name & Address where earned: Type of Institution: Public Private 2 Yr. 4 Yr. Major Field of Study/Discipline:

Other Degree Earned: Year Conferred: Institution Name & Address where earned: Type of Institution: Public Private 2 Yr. 4 Yr. Major Field of Study/Discipline:

Ethnic Background Personal Data

White (Not Hispanic or Latino) Asian Date of Birth: Black or African American (Not Hispanic or Latino) American Indian or Alaskan Married: Yes NoHispanic or Latino (Not Puerto Rican) Italian American Country of Birth: Puerto Rican Native Hawaiian or Other Pacific Islander

Were you ever employed by the City University of New York? Yes No

If yes, in what title

Where When 21

Rev. 3/07

22

The Graduate Center 365 Fifth Avenue, New York, NY 10016-4309

EMERGENCY CONTACT INFORMATION Name: ____________________ Home Address:____________________________________ Phone #:__________________ Primary Contact Person: _______________________________________ Relationship: _____________________________ Home Address:_______________________________________________________________ Phone #:__________________ Alternate Phone#:_________________________ E-mail address: _____________________________ If the Graduate Center cannot get in touch with contact named above, name a friend or relative who may be called. Secondary Contact Person: __________________________________________Relationship _________________________ Phone #:____________________________ Doctor’s Name: ___________________________ Address: _____________________ Phone #: ______________________

If none of the above can be reached, what do you wish the Graduate Center to do?

(It is understood that in the final disposition of an emergency case the judgment of the Center authorities will prevail. The recommendation indicated above will be respected as far as possible).

Identify any medications you are allergic to or any chronic conditions of which emergency personnel should be aware (optional):

I agree to notify the Office of Human Resources when/if the above information changes Signature: _________________________________________________________ Date:______________________________

Office of Human Resources

The Graduate Center

Release of Information

Print Name

NON-RELEASE

I DO NOT AUTHORIZE The Graduate Center (GC) officials to supply information concerning my status with the GC, including salary information, on written requests from banks, retail organizations and (credit rating services), without first consulting me. I agree to come to the Office of Human Resources, upon request, every time there is any inquiry on my status and to sign a specific release if I wish information released. Date Signature

GENERAL RELEASE I HEREBY AUTHORIZE The Graduate Center (GC) to supply information concerning my status, including salary information, on written request from banks, retail organizations, and (credit rating services). Such information may be given out further without consultation with me. I understand that it is the policy of the GC not to release information over the telephone. In an instance where I wish to have information given to an authorized person over the telephone, I will sign a separate release. Date Signature c: Personnel File

Office of Human Resources The Graduate Center

AMENDED CONSTITUTIONAL OATH UPON APPOINTMENT (in compliance with Section 62 of the NY State Civil Service Law)

“I do hereby pledge and declare that I will support The Constitution of the United States, and The Constitution of the State of New York

and that I will faithfully discharge the duties of the position of

(Contract Title)

according to the best of my ability.”

(Print Name)

(Signature)

(Street Address)

(Street Address)

(City) (State) (Zip Code)

Date:

Under the New York State Retirement and Social Security Law, retirees collecting a pension from New York State or New York City

cannot (with certain exceptions) work at the University and continue to collect their pension. Accordingly, The City University of New

York requires individuals seeking University employment to disclose their public employment and pension plan history for the

purpose of establishing eligibility for employment. An employee who fails to disclose such information will be subject to appropriate

action, which may include disciplinary action to terminate their employment and/or suspension or diminution of the retiree's public

pension benefits.

Note: Retirees who are under age 65 and are collecting a pension may receive an annual income of up to $30,000 (Thirty thousand only) in a position in public employment without diminution of their pension benefits. 1. Candidates for employment must submit this form at the time of hire, prior to any appointment

2. All full-time and part-time employees are responsible for submitting this form, should their status change

3. Adjuncts must submit this form every semester in which their employment continues

THE CITY UNIVERSITY OF NEW YORK EMPLOYMENT APPLICATION - PART THREE

CERTIFICATION OF NEW YORK STATE OR NEW YORK CITY PUBLIC SERVICE

CERTIFICATION OF COLLECTION OF PUBLIC PENSION FUNDS

CUNY Certification of NYS/NYC Public Service /Collection of Public Pension Funds Rev. 1-23-15

Date

Middle InitialLast Name First Name

Part-time Full-timeContract Title

DepartmentCollege

I am a New York State officer or employee (other than CUNY employee) and I receive compensation other than on a per diem basis

I am a member of the New York State Legislature

I am a New York State Legislative employee

I am a statewide elected official of New York State

Name of Employer

I am now working for another public service agency, organization, or jurisdiction funded by New York City or New York State

I am not currently working for another public service agency, organization, or jurisdiction funded by New York City or New York State, nor have I worked at any such entity during the calendar year

Current positions in Public Service (Please check appropriate box)

I am not collecting retirement benefit based upon this public service

Name of Pension Plan

I am collecting a retirement benefit from a public pension system (including ORP) maintained by the State or City of New York

I have no prior service with a public service agency, organization or jurisdiction funded by New York City or New York State

Prior positions in Public Service (Please check appropriate box)

of the City/State of New York, and I am former employee of

I hereby attest that the information I have provided above is correct to the best of my knowledge.

Signature Date

Name Signature Date

Office of Human Resources

Newand Your

PART A: General

1 An if the share of

by is no less of

Form Approved OMB No.

PART B: Information About Health Coverage Offered by Your Employer

3. 4.

5. 6.

8. 9. ZIP

10.

Information Concerning Union Membership and Agency Shop Fee Deductions for Instructional Staff Employees

in Titles Represented by the Professional Staff Congress/CUNY (“PSC”).

Most instructional staff positions -- both teaching and non-teaching -- are included in the unit represented by the Professional Staff Congress/CUNY, Local 2334, AFT, as the exclusive collective bargaining representative. (See “I”

below regarding “Included Positions.”) A few instructional staff positions are excluded from union representation because of the responsibilities of the position or the functions of the office. (See “II” below regarding “Excluded Positions.”)*

Included employees are governed by the terms of the PSC/CUNY collective bargaining agreement and may be represented by the PSC in grievance and disciplinary proceedings. Excluded employees are covered by terms and conditions of employment similar to those of employees represented by the PSC -- such as the same salary schedules, pension options, health plans and supplemental welfare fund benefits (e.g., drug, dental and optical) -- however, there are significant differences. For example, individuals who are excluded from representation do not have access to the grievance and disciplinary procedures contained in the collective bargaining agreement.

I. Included Positions

PSC Membership

If you wish to become a member of the PSC, you must submit a membership application to the Union. You may contact the PSC at (212) 354-1252. You may also print out an application for membership from the PSC website http://www.psc-cuny.org/about-us/membership. Send the filled-out form to the PSC at 61 Broadway, Suite 1500, NY, NY 10006. Union dues will automatically be deducted from your salary and remitted to the PSC. Dues-paying union members have the right to full participation in the union, including voting on proposed contracts and in union elections, as well as running for union office.

Agency Shop Fee Status

If you do not apply for PSC membership, you will not become a member of the union. Because the PSC represents you for collective bargaining and contract enforcement purposes, State law permits the union to collect an agency fee from you, which is automatically deducted from your salary and remitted to the PSC. Payment of the agency fee does not constitute membership in the union as described above. The amount of the agency fee is the same amount as union dues. Once a year, the union notifies agency fee payers of their ability to request a refund from the PSC for a pro rata share of the agency fee paid for expenditures of a political or ideological nature that are only incidentally related to terms and conditions of employment. Further information concerning this partial refund option may be found on the PSC website at http://www.psc-cuny.org/agency-fee-refund-procedures.

If you wish to change your status from an agency fee payer to a dues-paying member of the union, you must submit a membership application. (See above.)

II. Excluded Positions

Employees in titles in the PSC bargaining unit excluded from representation by the union because of the responsibilities of the position or the functions of the office are not eligible to join the union and do not pay dues or an agency fee deduction.

_____________________________________________________________________________________

*The lists of included and excluded titles are set forth in Article 1 of the PSC/CUNY collective bargaining agreement, which is available on-line at: http://www.cuny.edu/about/administration/offices/lr/lr-contracts/2007-2010CUNY-PSCcollectivebargainingagreement.pdf. If you are not certain whether you are appointed to an included or excluded position, you should check with your Human Resources Department, which can also answer any questions you may have concerning the terms and conditions of your employment.

Wageworks revised 04/12

UPDATED WAGEWORKS COMMUTER BENEFITS PROGRAM

ABOUT THE PROGRAM

All full-time and part-time employees are eligible to participate in the WageWorks Program. This program was designed to help employees save money by paying for their transportation expenses with pre-tax dollars.

By paying for these expenses with pre-tax dollars you will reduce your taxable income, and in turn, the amount of income tax you pay. You may choose from several Transportation Deduction Plans depending on your needs. You may enroll, make changes or terminate participation in the plan at any time during the year.

The Commuter Card Unrestricted Plan – a stored value card loaded with your deductions each pay date (twice a month) that can be used to purchase transit passes and tickets at transit providers throughout the New York Tri-state area. To see a list of where the Commuter Card will work – visit the website http://getwageworks.com/nyc/transitcard . You may use this card to purchase any transit fare media including, but not limited to MetroCards, Long Island Railroad, Metro-North Rail Road and New Jersey Transit tickets up to the balance on your card.

Transit Pass Plan – this plan allows you to arrange for home delivery of your transit provider passes and tickets.

The maximum monthly pre-tax transportation fringe benefit that an employee can take advantage of per Internal Revenue Code (IRC) Section 132 is $125.00.

Your taxable wages on your W-2 form in box 1, Social Security and Medicare wages in boxes 3 and 5, and state and local wages in boxes 17 and 20 will be reduced by the value of the pre-tax transportation deductions from your pay.

You will pay an administrative fee for account maintenance and transaction costs. Once a month this fee will be deducted post-tax from your paycheck. The Commuter Card Unrestricted Plan fee is $1.77 per month. Transit Pass Plan fee is $3.05 per month.

If you are no longer participating in the plan, you will have 90 days from the date of termination to spend down your account balance. Any unused fund remaining at the end of this period will be forfeited.

During months that include three payrolls, transportation deductions will only be taken on the first two payrolls of that month. Please plan accordingly.

If you change your address, please remember to indicate on the Address Change Form that you have a WageWorks Account and return the form to the Office of Human Resources in room 8403.

If you transfer to another CUNY school and wish to continue your participation in this program, you must notify The Graduate Center’s Office of Human Resources about this change.

Please contact Ms. Lenore Mitchell at LMitchell2@gc.cuny.edu or 212-817-7700 with any enrollment questions.

EMPLOYEE ACTIONNEW(Enroll)

CANCELLATION(Terminate Your Transit Plan Payroll Deduction)

Telephone

EMPLOYEE IDENTIFICATION (All fields in this section are required and must be filled out completely. Please Print.)

PAY DATE TO SUSPEND DEDUCTIONMONTH DAY YEAR MONTH DAY YEAR

PAY DATE TO RESUME DEDUCTION

Employee Signature

WW-TRANSITBENEFIT-FORM Jan 2013)

www.cuny.edu/transitbenefit www.getwageworks.com/nycSubmit completed form to: Your College TransitBenefit Coordinator

MonthlyDeduction Amount*

EmployeeInitials

$

MonthlyDeduction Amount*

EmployeeInitials

$

MonthlyDeduction Amount*

EmployeeInitials

$*For the Commuter Card – Unrestricted, Transit Pass and Access-A-Ride plans you may elect any amount up to $800 per month where the

first $245 will be deducted pre-tax and any amount over $245 will be deducted post-tax.

Submit at least 2 weeks before you want to suspend your deduction. Remember, administrative deductions will continue when applicable. If you are also enrolled in the Commuter Benefits Parking Plan, the parking plan will be suspended for the same period. Please note this will only suspend your payroll deduction. To also suspend your transit pass orders you must do so directly with Wageworks at www.wageworks.com or 1-877-924-3967.

I certify that the above data was entered in PayServ / PMS via EForms:

TRANSIT PLAN

Access-A-Ride

Commuter Card-Unrestricted

Transit Pass

CHARGE METHOD

Deducted from post-tax pay

Deducted from post-tax pay.

Deducted from post-tax pay.

FEE

$3.05

$1.77

$3.05

THE CITY UNIVERSITY OF NEW YORK COMMUTER BENEFITS PROGRAM

TRANSITBENEFIT PLANS

CHANGE PERSONAL INFORMATION (Change Mailing address, Email or Telephone)

SUSPEND DEDUCTION(Temporarily Stop Transit Plan Deduction from Pay)

CHANGE DEDUCTION (Change Transit Plan and/or Amount Deducted from Pay each Month)

Social Security / ERN #*

Name (First/Middle/Last)

Address Line 1

Address Line 2**

City/State/Zip

Email Address

* Located on your pay statement or check stub. ** Apt.#, Fl.# or Box# if applicable.

TRANSIT PLAN AUTHORIZATION ACCESS-A-RIDE

($3.05 Monthly Admin Fee through Payroll Deductions)

COMMUTER CARD - Unrestricted($1.77 Monthly Admin Fee

through Payroll Deductions)

TRANSIT PASS($3.05 Monthly Admin Fee

through Payroll Deductions)

SUSPEND TRANSIT PLAN DEDUCTION

Personal information updated in PayServ /PMS (check all that apply):

AGENCY PAYROLL SECTION

I hereby authorizeTthe City University of New York to deposit my payroll deduction as indicated above into my Wageworks Commuter Benefits Transit Account.

I also grant authorization for the reversal of a credit to my account in the event the credit was made in error. I understand that, under the “National Automated Clearing House Association” operating guidelines and rules, The City University of New York can only reverse the amount of the incorrect direct deposit.

I understand, according to the Internal Revenue Code, that the average monthly amount of my transportation deductions should not exceed my average monthly cost of public transportation to and from work. If my average monthly cost of public transportation to and from work should change, I will change my deduction plan to accommodate my new circumstance. Furthermore, no reimbursement will be provided for pre-tax transportation fringe deductions. Upon cancellation, voluntary or otherwise, any funds remaining in my Transit Account will be available for use for a period of 90 days from the effective date of cancellation. Residual funds remaining in the account beyond the 90 day period will be forfeited.

I understand there is a monthly fee to cover administrative costs of the program. Said fee will deducted from my post-tax pay each month. The administrative charge is non-refundable. The administrative fees and charges are as follows:

I grant authorization for The City University of New York to provide my enrollment information, including mailing address, phone number and e-mail address to Wageworks for uses exclusively related to the administration of the program.

I understand that this authorization will remain in effect until I submit a new request for a change or cancellation.

I understand that my Commuter Benefits transit account balance and information will be maintained by Wageworks and are accessible online at www.wageworks.com or by calling Wageworks Customer Service at 1-877-WageWorks (1-877-924-3967).

EMPLOYEE CERTIFICATION

(Please select One of the following plans by writing your initials in the column next to the Transit Plan of your choice. Please enter the total amount, including dollars and cents, you want deducted from your pay each month.)

DATE

MONTH DAY YEAR

PMS ENTRY DATE

MONTH DAY YEARMailingAddress

EmailAddress

PhoneNumber

Prepared By (Please Print)

Payroll #

Signature Date

D.O.B MM_ _ / DAY _ _ /