NewHireEmployeeCoverSheetWelcometotheMaricopaCommunityColleges!

Upon confirmation of hire, please complete and return all of the following documents. As a new member of the MCCCD community, you are required to complete and return the attached paperwork before you can be paid. Once completed, this packet may be shared by all colleges/locations within MCCCD.

Please return this packet in person to .

If you have any questions, please call .

Helpful telephone numbers for information: Internal Revenue Service (IRS): 1-800-829-1040; Social Security Administration: 1-800-772-1213.

1. EMPLOYMENT ELIGIBILITY. Form I-9* (Employment Eligibility Verification Form). Federal law requires

employees to complete a Form I-9 within the time delays specified below each time an employer hires an employee to work or receive any form of remuneration for labor or services rendered.

• The employee must complete and sign Section 1 of Form I-9 no later than their first day of employment and no sooner than the employee has accepted the offer of employment.

• The employee must present specific original documents (per the attached Lists of Acceptable Documents) to a Form I-9 Representative within three (3) business days of the date of employment begins.

The hiring supervisor will be responsible for compliance, making sure the employee meets with local HR to verify the identity and employment authorization of the hired individual by completing the Form I-9/E-Verify process. Both employees and employers must complete the Form. The standard practice of Maricopa Community Colleges is to complete the entire I-9 process prior to the employee’s first day of work, but never before the person has accepted employment.

*The Lists of Acceptable Documents and Form I-9 Instructions are provided in this packet.

2. NEW EMPLOYEE DATA FORM.

3. STATE & FEDERAL TAX FORMS. Print legibly using a pen with blue or black ink. Print your name and social security number as it appears on your social security card.

• NON-RESIDENT ALIENS: Submit a Non-U.S. Citizen Employee Tax Form (Not intended for Permanent Residents or Employment Authorization Card holders without terms listed).

4. WAGE WITHHOLDING FORM DEPARTMENT OF ECONOMIC SECURITY.

5. ARIZONA STATE RETIREMENT SYSTEM (ASRS) ACKNOWLEDGEMENT.

6. ARIZONA STATE RETIREMENT SYSTEM (ASRS) ELIGIBILITY DECLARATION.

7. INVITATION TO SELF IDENTIFY – DISABILITY AND PROTECTED VETERAN STATUS.

8. LOYALTY OATH (for U.S. Citizens and permanent residents).

9. ACA PAPERWORK (informational).

10. AUTHORIZATION TO MAIL PAYCHECK (optional).

11. DIRECT DEPOSIT AUTHORIZATION (optional).

For Adjunct and Substitute Faculty

1. RESUME or CURRICULUM VITAE.

2. OFFICIAL TRANSCRIPTS (unofficial transcripts are acceptable until officials come in)

3. CREDENTIALS VERIFICATION

4. ADJUNCT FACULTY EMPLOYEE HANDBOOK ACKNOWLEDGMENT FORM. • All new employees will complete the MCCD SIS-FERPA/College Records tutorial online.

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

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

LIST A

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

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

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

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

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

Documents that Establish Both Identity and

Employment Authorization

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

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

and(2) An endorsement of the alien's

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

a. Foreign passport; and

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

listed above:

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

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

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

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

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

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

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

4. Native American tribal document

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

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

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

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

Refer to the instructions for more information about acceptable receipts.

Human Resources Revised: May 2018

New Employee Data Form

NAME Print your Full Name as it appears on your Social Security Card

BIRTH DATE SSN mm/dd/yy

ADDRESS

Street Address (w/Apt. No. if Applicable) City State Zip

MAIN PHONE ( ) OTHER PHONE ( ) E-MAIL Ok to release ( ) Ok to text ( ) Ok to release ( ) Ok to text ( )

EMERGENCY CONTACT ( ) ( ) INFORMATION Contact’s Name Relationship Contact’s main phone Contact’s Work Phone

Contact’s Address

Provide the following information if you are currently employed at another Maricopa Community College location:

College(s)/Location(s) and Department(s) Supervisor(s) Total Hours per Week (indicate Clock or Load Hours)

Provide the following if you have been employed at another Maricopa Community College in the last 5 years:

/ Campus Supervisor Year Campus Supervisor Year

Signature of Employee Date

STATEMENT OF REGISTRATION STATUS Per Arizona Revised Statute 38-201, effective September 30, 1988, “a male person born after December 31, 1960 is not eligible to hold any office, employment or service in any public institution in Arizona unless the person has registered with the selective service system if required by the federal military selective service act .”

By my signature below, I assert that all the information given in this packet is true. I understand that false information (misrepresentation or omission of information) may be the basis for termination of employment. I authorize investigation of all statements contained herein and hereby release all parties from any liability for any damages that may result from furnishing such information.

HR Use Only

CAMPUS _____________ □ STUDENT □ TEMPORARY □ ADJUNCT EMPLID _____________________ SIS ___________________ CAMPUS EMAIL ________________________________________________________

Form I-9 Date: _ □ Loyalty Oath □ State/Federal Tax Forms □ Wage Withholding □ ASRS Eligibility/Acknowledgement □ Self ID Dis/Vet

ADJUNCT □ Resume/CV □ Transcripts □ Conditions of Employment □ Credentials Verification Input by:_____________________________________________________________ Date: _________________________________

Human Resources Revised: May 2018

Text message MEMS (Maricopa Emergency Management System) ALERTS: All employees are enrolled in a text-message ALERT notification system that sends messages with key directives in the event of incidents affecting the health and safety of people on campus/site when a cell phone number is entered into HRMS.

The ALERTS are issued in a specific format that makes it clear you are being notified of an emergency (MEMS ALERT, CGCC ALERT, MCC ALERT, GCC ALERT, etc.) The alerts provide directives with which you are expected to comply.

It is important to keep your contact information updated in HRMS (employees) – especially mobile devices and e-mail addresses – in order to fully utilize the MEMS Alert system. Anyone may opt-out of the mass notification system through a link on the MEMS website, or by responding S-T-O-P to test text messages. However, it is highly recommended that you remain enrolled.

Type or print your Full Name Your Social Security Number

Home Address – number and street or rural route

City or Town State ZIP Code

Choose either box 1 or box 2: 1 Withhold from gross taxable wages at the percentage checked (check only one percentage):

0.8% 1.3% 1.8% 2.7% 3.6% 4.2% 5.1%

Check this box and enter an extra amount to be withheld from each paycheck ................ $

2 I elect an Arizona withholding percentage of zero, and I certify that I expect to have no Arizona tax liability for the current taxable year.

Employee’s Instructions

Arizona law requires your employer to withhold Arizona income tax from your wages for work done in Arizona. The amount withheld is applied to your Arizona income tax due when you file your tax return. The amount withheld is a percentage of your gross taxable wages from every paycheck. You may also have your employer withhold an extra amount from each paycheck. Complete this form to select a percentage and any extra amount to be withheld from each paycheck.

What are my “Gross Taxable Wages”?For withholding purposes, your “gross taxable wages” are the wages that will generally be in box 1 of your federal Form W-2. It is your gross wages less any pretax deductions, such as your share of health insurance premiums.

New EmployeesComplete this form within the first five days of your employment to select an Arizona withholding percentage. You may also have your employer withhold an extra amount from each paycheck. If you do not file this form, the department requires your employer to withhold 2.7% of your gross taxable wages.

Current EmployeesIf you want to change your current amount withheld, you must file this form to change the Arizona withholding percentage to change the extra amount withheld.

What Should I do With Form A-4?Give your completed Form A-4 to your employer.

Electing a Withholding Percentage of ZeroYou may elect an Arizona withholding percentage of zero if you expect to have no Arizona income tax liability for the current year. Arizona tax liability is gross tax liability less any tax credits, such as the family tax credit, school tax credits, or credits for taxes paid to other states. If you make this election, your employer will not withhold Arizona income tax from your wages for payroll periods beginning after the date you file the form. Zero withholding does not relieve you from paying Arizona income taxes that might be due at the time you file your Arizona income tax return. If you have an Arizona tax liability when you file your return or if at any time during the current year conditions change so that you expect to have a tax liability, you should promptly file a new Form A-4 and choose a withholding percentage that applies to you.

Voluntary Withholding Election by Certain Nonresident EmployeesCompensation earned by nonresidents while physically working in Arizona for temporary periods is subject to Arizona income tax. However, under Arizona law, compensation paid to certain nonresident employees is not subject to Arizona income tax withholding. These nonresident employees need to review their situations and determine if they should elect to have Arizona income taxes withheld from their Arizona source compensation. Nonresident employees may request that their employer withhold Arizona income taxes by completing this form to elect Arizona income tax withholding.

I certify that I have made the election marked above.

SIGNATURE DATE

ADOR 10121 (17)

Arizona Form

A-4 Employee’s Arizona Withholding Election 2018

Form W-4 (2018)Future developments. For the latest information about any future developments related to Form W-4, such as legislation enacted after it was published, go to www.irs.gov/FormW4.Purpose. Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay. Consider completing a new Form W-4 each year and when your personal or financial situation changes.Exemption from withholding. You may claim exemption from withholding for 2018 if both of the following apply.• For 2017 you had a right to a refund of all federal income tax withheld because you had no tax liability, and• For 2018 you expect a refund of all federal income tax withheld because you expect to have no tax liability.If you’re exempt, complete only lines 1, 2, 3, 4, and 7 and sign the form to validate it. Your exemption for 2018 expires February 15, 2019. See Pub. 505, Tax Withholding and Estimated Tax, to learn more about whether you qualify for exemption from withholding.

General InstructionsIf you aren’t exempt, follow the rest of these instructions to determine the number of withholding allowances you should claim for withholding for 2018 and any additional amount of tax to have withheld. For regular wages, withholding must be based on allowances you claimed and may not be a flat amount or percentage of wages.

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

using this calculator if you have a more complicated tax situation, such as if you have a working spouse, more than one job, or a large amount of nonwage income outside of your job. After your Form W-4 takes effect, you can also use this calculator to see how the amount of tax you’re having withheld compares to your projected total tax for 2018. If you use the calculator, you don’t need to complete any of the worksheets for Form W-4.

Note that if you have too much tax withheld, you will receive a refund when you file your tax return. If you have too little tax withheld, you will owe tax when you file your tax return, and you might owe a penalty.Filers with multiple jobs or working spouses. If you have more than one job at a time, or if you’re married and your spouse is also working, read all of the instructions including the instructions for the Two-Earners/Multiple Jobs Worksheet before beginning. Nonwage income. If you have a large amount of nonwage income, such as interest or dividends, consider making estimated tax payments using Form 1040-ES, Estimated Tax for Individuals. Otherwise, you might owe additional tax. Or, you can use the Deductions, Adjustments, and Other Income Worksheet on page 3 or the calculator at www.irs.gov/W4App to make sure you have enough tax withheld from your paycheck. If you have pension or annuity income, see Pub. 505 or use the calculator at www.irs.gov/W4App to find out if you should adjust your withholding on Form W-4 or W-4P. Nonresident alien. If you’re a nonresident alien, see Notice 1392, Supplemental Form W-4 Instructions for Nonresident Aliens, before completing this form.

Specific InstructionsPersonal Allowances WorksheetComplete this worksheet on page 3 first to determine the number of withholding allowances to claim.Line C. Head of household please note: Generally, you can claim head of household filing status on your tax return only if you’re unmarried and pay more than 50% of the costs of keeping up a home for yourself and a qualifying individual. See Pub. 501 for more information about filing status.Line E. Child tax credit. When you file your tax return, you might be eligible to claim a credit for each of your qualifying children. To qualify, the child must be under age 17 as of December 31 and must be your dependent who lives with you for more than half the year. To learn more about this credit, see Pub. 972, Child Tax Credit. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line E of the worksheet. On the worksheet you will be asked about your total income. For this purpose, total income includes all of your wages and other income, including income earned by a spouse, during the year.Line F. Credit for other dependents. When you file your tax return, you might be eligible to claim a credit for each of your dependents that don’t qualify for the child tax credit, such as any dependent children age 17 and older. To learn more about this credit, see Pub. 505. To reduce the tax withheld from your pay by taking this credit into account, follow the instructions on line F of the worksheet. On the worksheet, you will be asked about your total income. For this purpose, total income includes all of

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

Form W-4Department of the Treasury Internal Revenue Service

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

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

OMB No. 1545-0074

20181 Your first name and middle initial Last name

Home address (number and street or rural route)

City or town, state, and ZIP code

2 Your social security number

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

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

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

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

5 Total number of allowances you’re claiming (from the applicable worksheet on the following pages) . . . 56 Additional amount, if any, you want withheld from each paycheck . . . . . . . . . . . . . . 6 $7 I claim exemption from withholding for 2018, and I certify that I meet both of the following conditions for exemption.

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

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

Employee’s signature (This form is not valid unless you sign it.) ▶ Date ▶

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

9 First date of employment

10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 4. Cat. No. 10220Q Form W-4 (2018)

Human Resources Revised: May 2018

WAGE WITHHOLDING INFORMATION AS REQUIRED BY THE STATE OF ARIZONA DEPARTMENT OF ECONOMIC SECURITY

Effective July 1, 1994, Arizona Revised Statute 23-722.02 requires that all employers ask newly hired employees, rehired employees, and employees returning from leave without pay status if they are subject to any active child support wage withholding.

To comply with this statute, please complete and sign as indicated below: ________ I hereby certify that I am NOT subject to a child support wage

withholding order. ________ I AM subject to a child support wage withholding order. I understand

that it is my obligation to supply MCCD with a copy of any active order of assignment.

PRINT NAME_______________________________________________

SS#________________________________________________________

SIGNATURE________________________________________________

DATE__________________________________________

Human Resources Revised: May 2018

ARIZONA STATE RETIREMENT SYSTEM

ACKNOWLEDGEMENT As an employee of Maricopa County Community Colleges District (MCCCD) you may become eligible to participate in the Arizona State Retirement System (ASRS). The ASRS is a defined benefit plan and is tax qualified under section 401(a) of the Internal Revenue Code. It provides a lifelong benefit based on years of service earned, or worked, and your ending salary average. Eligibility is defined by State Statute 38-727. An employee must be engaged to work at least 20 clock hours per week for 20 weeks in a fiscal year. The fiscal year is defined as July 1 to June 30th. Eligibility in ASRS is independent of any qualified Maricopa County Community Colleges District Benefit Programs, and is eligible for audit by ASRS. In the event of an audit all administrative actions by MCCCD will be governed by ASRS. For more detailed information on the Arizona State Retirement System, please review the website at AZASRS.GOV. Your signature indicates that you have read and understand the aforementioned information. You also understand that ASRS is the knowledge source and has final determination in any administrative action regarding the Arizona State Retirement System. MCCCD employees are obligated to notify their local Human Resources department or the District Office Retirement Analyst if they believe contributions are being withheld in error. Print Name________________________ Employee ID_______________ ____________________________________________________________ Signature ____________________________________ Date

Return completed form to the District Office Benefits Department

Human Resources Revised: May 2018

ARIZONA STATE RETIREMENT SYSTEM

ELIGIBILITY DECLARATION

Name (please print) Social Security Number

Mailing Address Day Phone Evening Phone

City State Zip Work Location (college/dept.)

Please check the box if any of these situations pertain to you.

Retired Employee through the Arizona State Retirement System: I am a part-time employee currently receiving a pension from Arizona State Retirement, and have retired from on . I understand that if I teach more than 10 load hours per semester, or work 20 or more hours per week, for any 20 weeks during the first year following my retirement, I will resume making contributions to the retirement system and may have to repay my pension benefit.

I am a part-time employee currently receiving a pension from Arizona State Retirement, and have retired from on as an early retiree. I understand that if I teach more than 10 load hours per semester, or work 20 or more hours per week, for any 20 weeks while I am classified as an early retiree, I will resume making contributions to the retirement system and may have to repay my pension benefit.

I am a retiree receiving a pension from the Arizona State Retirement System. I retired from on as a normal retiree. I have been retired for at least 12 months. I am returning to work under HB 2050 legislation in a full time governing board approved position , or as an adjunct faculty teaching more than 7.5 load hours , or as a temporary employee working 20 hours or more per week . (Check one)

Part Time Adjunct Faculty Employee:

I am a part time faculty person, teaching evening only classes. I elect to contribute not less than 7.5% of my pay to a TSA and be exempt from contributing to FICA. Attached is my completed TSA Enrollment Form, which names the TSA Company I have selected and the percent that I want to contribute.

None of the above applies

Signature Date

Human Resources Revised: May 2018

ASRS Retiree Return to work: If an ASRS pensioner (rehired annuitant) returns to work with any ASRS employer during their first 12 months after retirement, and is engaged to work for a period that does not meet ASRS active membership criteria, the rehired annuitant is entitled to continue to receive ASRS pension benefits. A rehired annuitant does not resume ASRS active member statue if: (1) work under 20 hours per week; (2) work up to 19 weeks at 20 or more hours a week; (3) work up to 19 weeks at 20 or more hours a week and under 20 hours for the remainder of the fiscal year. If the rehired annuitant resumes active membership the annuitant’s ASRS benefit must be suspended and the rehired employee will make ASRS contributions.

A member who has been retired for 12 months (not meeting conditions for ASRS active membership) may return to work or continue to work any amount of time and continue to receive pension benefits. Such members will not have retirement contributions withheld from their pay and not to accrue additional credited service or LTD benefits. At any time, rehired annuitants can suspend their retirement benefit and resume active member status. While the member remains in active status, the member will earn additional credited service and can re-retire with a higher benefit

Tax Sheltered Annuity in Lieu of FICA: The United States Congress amended the Omnibus Budget Reconciliation Act of 1990 to require service of all part-time employees to become subject to the social security tax unless the employee is a member of a “retirement plan”. A tax-sheltered annuity (TSA) program maintained under Section 403(b) of the Internal Revenue Code is considered a “retirement plan”. Evening only credit instructors are considered part time employees. However, if the evening teaching load becomes 7.5 load hours or more, the employee is no longer considered part-time for purposes of this legislation. Full social security taxes (FICA) will be deducted from the employees pay even if a TSA option is chosen. Evening faculty teaching greater than 7.5 load hours, day credit and non-credit faculty, and other part time employees can also participate in the TSA program in addition to FICA. ASRS rehired annuitants may contribute to a TSA.

MAKE A COPY FOR YOUR RECORDS BEFORE MAILING TO: Maricopa County Community College District Employee Benefits Department 2411 W. 14th Street Tempe, AZ 85281-6942

This election will remain in effect until a written request to change has been received.

Human Resources Revised: May 2018

PROTECTED VETERAN POST-OFFER INVITATION TO SELF-IDENTIFY The Maricopa Community College District is a Government contractor subject to the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended by the Jobs for Veterans Act of 2002, 38 U.S.C. 4212 (VEVRAA), which requires Government contractors to take affirmative action to employ and advance in employment: (1) disabled veterans; (2) recently separated veterans; (3) active duty wartime or campaign badge veterans; and (4) Armed Forces service medal veterans. These classifications are defined as follows: A "disabled veteran" is one of the following:

• A veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or

• A person who was discharged or released from active duty because of a service connected disability. A "recently separated veteran" means any veteran during the three-year period beginning on the date of such veteran’s discharge or release from active duty in the U.S. military, ground, naval, or air service. An "active duty wartime or campaign badge veteran" means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense. An "Armed forces service medal veteran" means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985. If you believe you belong to any of the classifications of protected veterans listed above, please indicate by selecting the appropriate option below. As a Government contractor subject to VEVRAA, MCCCD is required to submit a report (VETS-100A) to the United States Department of Labor each year identifying the number of our employees belonging to each “protected veteran” category. We are also requesting this information in order to measure the effectiveness of the outreach and positive recruitment efforts we undertake pursuant to VEVRAA. I identify as one or more of the classifications of protected veteran listed:

□ Disabled Veteran

□ Recently Separated Veteran

□ Active Duty Wartime or Campaign Badge Veteran

□ Armed Forces Service Medal Veteran

□ I am a protected veteran, but I choose not to self-identify the classification to which I belong

□ I am not a protected veteran

□ I am not a veteran

REASONABLE ACCOMMODATIONS If you are a disabled veteran it would assist us if you tell us whether there are accommodations we could make that would enable you to perform the essential functions of the job, including special equipment, changes in the physical layout of the job, changes in the way the job is customarily performed, provision of personal assistance services or other accommodations. This information will assist us in making reasonable accommodations for your disability. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information provided will be used only in ways that are not inconsistent with the Vietnam Era Veterans’ Readjustment Assistance Act of 1974, as amended. The information you submit will be kept confidential, except that (i) supervisors and managers may be informed regarding restrictions on the work or duties of disabled veterans, and regarding necessary accommodations; (ii) first aid and safety personnel may be informed, when and to the extent appropriate, if you have a condition that might require emergency treatment; and (iii) Government officials engaged in enforcing laws administered by the Office of Federal Contract Compliance Programs, or enforcing the Americans with Disabilities Act, may be informed. Name: ________________________________________________________ Date: _______________________

Signature: _____________________________________________________ Job Title: ____________________________

Human Resources Revised: May 2018

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY Why are you being asked to complete this form?

Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completed this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way.

If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear or any punishment because you did not indetify as having a disability earlier.

How do I know if I have a disability?

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition.

Disabilities include, but are not limited to:

• Blindness • Deafness • Cancer • Diabetes • Epilepsy

• Autism • Cerebral palsy • HIV/AIDS • Schizophrenia • Muscular

dystrophy

• Bipolar Disorder • Major depression • Multiple sclerosis (MS) • Missing limbs or

partially missing limbs

• Post-traumatic stress disorder (PTSD)

• Obsessive compulsive disorder • Impairments requiring the use

of wheelchair • Intellectual disability (previously

called mental retardation

Please check one of the boxes below:

Yes, I have a disability (or previously had a disability) No, I don’t have a disability I don’t wish to answer

Please indicate, if known: Job ID #:

Job Title:

MCCCD does not discriminate in employment on the basis of race, color, national origin, age, sex, sexual orientation, disability, protected veteran, marital, or any other protected status covered by federal, state or local law.

Applicant Name: Date:

(Please print) Applicant Signature:

Human Resources Revised: May 2018

VOLUNTARY SELF-IDENTIFICATION OF DISABILITY

Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.

i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the U.S. Department of Labor’s Office of Federal Contrac Compliance Programgs (OFCCP) website at www.dol.gov/ofccp.

Reasonable Accommodation Notice

Human Resources Revised: May 2018 Retention: 5 years following last date paid

(signature of employee or officer)

Date

State of Arizona, County of Maricopa, I, (type or print name)

do solemnly swear, (or affirm) that I will support the Constitution of the United States and the Constitution and laws of the State of Arizona; that I will bear true faith and allegiance to the same, and defend them against all enemies,

foreign and domestic, and that I will faithfully and impartially discharge the duties of the office of

according to the best of my ability, (job title/name of office)

so help me God (or so I do affirm).

PUBLIC EMPLOYEE OR OFFICER LOYALTY OATH

Maricopa Community Colleges is required by state law to reproduce the following statute and obtain each employee's signature. A.R.S. § 38-231

Officers and employees required to take loyalty oath; form; classification;

In order to insure the statewide application of this section on a uniform basis, each board, commission, agency and independent office of the state, and any of its political subdivisions, and of any county, city, town, municipal corporation, school district, and public educational institution, shall immediately upon the effective date of this act completely reproduce § 38-231 as set forth herein, to the end that the form of written oath or affirmation required herein shall contain all of the provisions of said section for use by all officers and employees of all boards, commissions, agencies and independent offices.

For the purposes of this section, the term officer or employee means any person elected, appointed,

or employed, either on a part-time or full-time basis, by the state, or any of its political subdivisions or any county, city, town, municipal corporation, school district, public educational institution, or any board, commission or agency of any of the foregoing.

Any officer or employee elected, appointed or employed prior to the effective date of this act shall

not later than ninety days after the effective date of this act take and subscribe the form of oath or affirmation set forth in this section.

Any officer or employee within the meaning of this section who fails to take and subscribe the oath

or affirmation provided by this section within the time limits prescribed by this section shall not be entitled to any compensation unless and until such officer or employee does so take and subscribe to the form of oath or affirmation set forth in this section.

Any of the persons referred to in Article XVIII, Section 10 of the Arizona Constitution as amended,

related to the employment of aliens, shall be exempted from any compliance with the provisions of this section.

In addition to any other form of oath or affirmation specifically provided by law for an officer or

employee, before any officer or employee enters upon the duties of his office or employment, he shall take and subscribe the following oath or affirmation:

New Health Insurance Marketplace Coverage Options and Your Health Coverage

PART A: General Information

When key parts of the health care law take effect in 2014, there will be a new way to buy health insurance : the Health

Insurance Marketplace. To assist you as you evaluate options for you and your family, this notice provides some basic

information about the new Marketplace and employment based health coverage offered by your employer. If you are a

MCCCD benefits eligible employee, you do not qualify for a tax credit in the Health Insurance Marketplace. If you are not

eligible for MCCCD benefit plans, you may qualify for a tax credit. Please continue reading for additional information on the

Health Insurance Marketplace.

What is the Health Insurance Marketplace?

The Marketplace is designed to help you find health insurance that meets your needs and fits your budget. The Marketplace

offers "one-stop shopping" to find and compare private health insurance options. You may also be eligible for a new kind of tax

credit that lowers your monthly premium right away. Open enrollment for health insurance coverage through the Marketplace

begins in October 2013 for coverage starting as early as January 1, 2014.

Can I Save Money on my Health Insurance Premiums in the Marketplace?

You may qualify to save money and lower your monthly premium, but only if your employer does not offer coverage, or offers

coverage that doesn't meet certain standards. The savings on your premium that you're eligible for depends on your

household income. MCCCD health coverage does meet the required standards.

Does Employer Health Coverage Affect Eligibility for Premium Savings through the Marketplace?

Yes. If you have an offer of health coverage from your employer that meets certain standards, you will not be eligible for a tax

credit through the Marketplace and may wish to enroll in your employer's health plan. However, you may be eligible for a tax

credit that lowers your monthly premium or a reduction in certain cost-sharing if your employer does not offer coverage to you

at all or does not offer coverage that meets certain standards. If the cost of a plan from your employer that would cover you

(and not any other members of your family) is more than 9.5% of your household income for the year, or if the coverage your

employer provides does not meet the "minimum value" standard set by the Affordable Care Act, you may be eligible for a tax

credit.1

Note: If you purchase a health plan through the Marketplace instead of accepting health coverage offered by your employer,

then you may lose the employer contribution (if any) to the employer-offered coverage. Also, this employer contribution -as

well as your employee contribution to employer-offered coverage- is often excluded from income for Federal and State income

tax purposes. Your payments for coverage through the Marketplace are made on an after-tax basis.

How Can I Get More Information?

For more information about your coverage offered by your employer, please check your summary plan description or contact

the Maricopa County Community College District human resource offices.

The Marketplace can help you evaluate your coverage options, including your eligibility for coverage through the Marketplace

and its cost. Please visit HealthCare.gov for more information, including an online application for health insurance coverage

and contact information for a Health Insurance Marketplace in your area.

1 An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the

plan is no less than 60 percent of such costs.

Form Approved

OMB No. 1210-0149 (expires 11-30-2013)

86-0185552 2411 W. 14

th Street 480-731-8581

Tempe AZ 85281-6942 MCCCD Employee Benefits Hotline

PART B: Information About Health Coverage Offered by Your Employer This section contains information about any health coverage offered by your employer. If you decide to complete an application for coverage in the Marketplace, you will be asked to provide this information. This information is numbered to correspond to the Marketplace application.

3. Employer name

4. Employer Identification Number (EIN)

Maricopa County Community College District

5. Employer address 6. Employer phone number

7. City 8. State 9. ZIP code

10. Who can we contact about employee health coverage at this job?

11. Phone number (if different from above) 12. Email address rx@domail.maricopa.edu

Here is some basic information about health coverage offered by this employer:

As your employer, we offer a health plan to: All employees.

X Some employees. Eligible employees are:

As a Maricopa County Community College District (MCCCD) employee, you are eligible to participate in MCCCD’s health plan if you are employed by MCCCD per the following definition:

Persons who occupy a regular, classified, non-classified, Skill Center or Specially-funded non-faculty position scheduled to work at least 20 hours per week on a regularly scheduled basis for at least nine months per fiscal year, or persons who occupy a residential faculty position who carry at least a half-time instructional load. One-year-only (OYO) or one-semester-only (OSO) positions are only eligible for coverage as defined in the MCCCD Temporary Rates document available at: http://www.maricopa.edu/employees/divisions/hr/managing/hiring/shortterm

With respect to dependents:

X We do offer coverage. Eligible dependents under a MCCCD covered benefits eligible employee are: Employee's spouse under a legally valid existing marriage.

Employee's children or the children of his/her spouse until age 26. This includes natural children, legally-adopted children, step children, children placed for adoption, children under legal guardianship substantiated by a court order and living with the employee and children who are entitled to coverage under a medical support order. You may cover the child whether he or she is a fulltime student, lives with the employee, is eligible for other group health coverage, or is financially dependent on the employee. Children under the age of 19 will not be subject to pre-existing condition limitations on MCCCD medical plans. A domestic partner, and the children of the domestic partner as defined below, are eligible to enroll for group coverage as dependents on the same basis as other eligible dependents as long as the following criteria are met: Domestic Partner: An individual of either sex who has shared a long-term committed Domestic Partnership relationship with an eligible employee for a minimum of the last 6 months. Children of a Domestic Partner until age 26: The children of the domestic partner, including natural children, legally adopted children and children under legal guardianship substantiated by a court order. These children are eligible for dependent coverage if they are primarily dependent on the domestic partnership for support, reside with the domestic partners in a regular parent child relationship, meet the age requirements of the benefit plan and meet the definition of an eligible child under the Internal Revenue Service Code § 152. Children under the age of 19 will not be subject to pre-existing condition limitations on MCCCD medical plans. Domestic Partnership: A relationship between an eligible employee and his/her domestic partner that meets all of the following criteria: The partners currently reside together in an exclusive mutual commitment similar to marriage and have done so for at least the last 6 consecutive months and each intend to continue the relationship indefinitely;

The partners are jointly responsible for basic living expenses;

The partners are not married to each other or any other individual (statutory or common law), and neither is a member of another domestic partnership;

Both partners are 18 years old or older;

Partners are not related by blood or a degree of closeness which would prohibit marriage under the law of the State of Arizona;

Both partners were mentally competent to consent to contract when the domestic partnership began and remain so for purposes of contracting for coverage for the domestic partner;

Each partner is the other’s sole domestic partner and is responsible for the other’s common welfare;

The partners are financially interdependent, jointly responsible for each other’s basic living expenses and able to provide documents for at least three (3) of the following situations to demonstrate that interdependence has existed for a minimum of the last 6 consecutive months:

joint mortgage, joint property tax identification or joint tenancy on a residential lease;

joint bank, investment and/or credit account;

joint liabilities (e.g., credit cards, automobile loans);

joint ownership of real property or a common leasehold, interest in real property, such as a residence or business, or common ownership of an automobile;

a Will which designates the other as the primary beneficiary or a beneficiary designation form currently in effect for a retirement plan or life insurance policy setting forth that one partner is a beneficiary of the other;

designation of one partner as holding power of attorney for health care or a general durable power of attorney for the other;

written agreement(s) or contracts regarding the domestic partner relationship showing mutual support obligations.

We do not offer coverage.

X If checked, this coverage meets the minimum value standard, and the cost of this coverage to you is intended to be affordable, based on employee wages.

** Even if your employer intends your coverage to be affordable, you may still be eligible for a premium discount

through the Marketplace. The Marketplace will use your household income, along with other factors, to determine whether you may be eligible for a premium discount. If, for example, your wages vary from week to week (perhaps you are an hourly employee or you work on a commission basis), if you are newly employed mid-year, or if you have other income losses, you may still qualify for a premium discount.

If you decide to shop for coverage in the Marketplace, HealthCare.gov will guide you through the process, or contact the Marketplace by phone at: 1-800-318-2596 TTY: 1-855-889-4325.

Direct Deposit Instructions

Please Read Carefully 1. You now have the option of Direct Deposit to one account or to split it between 2 accounts as long as the financial institution is recognized by the Arizona Clearinghouse system. You must deposit all of your net check. Please complete your request for direct deposit as follows:

Examples Only: If you want your entire direct deposit to go into one account (all fields required) Bank Routing ABA (9 digit number)

Account Type Checking/Savings

Account #

Will be 100% of net pay

1. 123456789 Checking 00098756452 100% If you want your earnings to be distributed to 2 different accounts (all fields required) Bank Routing ABA (9 digit number)

Account Type Checking/Savings

Account #

One account must be $ amount and 2nd account must be Bal of net pay

1. 123456789 Savings 00098756452 $50.00 2. 987654321 Checking 00025465787 Bal of net pay If you need to cancel the direct deposit with the set dollar amount, your entire net pay will then be deposited to the account where you have requested the balance of net pay. If you stop/cancel the direct deposit into which the balance of net pay goes, then both accounts will need to be stopped. Your net pay must be entirely Direct Deposit or entirely live check. Mail the form to: District Support Services OR FAX to: 480-731-8405 Attn: Payroll 2411 W 14th Street Tempe, AZ 85281 Or your may take your form to your Campus HR Department and they will send it to the District Office for you. Direct Deposit will be cancelled for adjunct faculty, students and temporary employee’s if they have not received pay in the last four (4) months. Page 1 of 2 Form on back side

Direct Deposit Authorization/Change Form

Choose One: New _____ Add _____ Change _____ Stop _____ Employee Name: Please Print Last Name First Name Social Security # or Employee ID Campus Location (1) Bank Name (Required): Bank Branch Phone # (2) Bank Name (Required): Bank Branch Phone #

(All Fields are Required)

Bank Routing ABA (9 digit number)

Account Type Checking/Savings

Account # For two accounts: One needs to be $ amount & second acct. must be Bal of net pay

1.

2.

I (we) hereby authorize MCCCD to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my (our) checking or savings account and the deposit names above, to credit and/or debit the same such account. I (we) understand this remains in effect until written notice of cancellation is submitted. Signature: Daytime Phone # Required Payroll Use Only Date Processed by

Please attach the acceptable forms of documentation For Checking Accounts:

1. Voided Check or Copy of Bank Account Identification (must show routing number as well as Account number) For Savings Accounts:

1. Copy of Bank Account Identification (must show Routing number as well as Account number) 2. Deposit slips will not be accepted

Revised 2/25/15 Page 2 of 2 Instructions on back side

Please fill in all information