temporary-hourly, new employee checklist papers... · 2020-07-09 · to be checked by hr required...

The Office of Human Resources is located at 2277 Napa Vallejo Highway, Napa, CA 94558 | Room 1544

OHR FEB. 2020

New Employee Name:

--------------------------------------- Requesting Dept:

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Office of Human Resources, Training & Development Phone: 707-256-7100

TEMPORARY-HOURLY, NEW EMPLOYEE CHECKLIST

New employees CANNOT begin an assignment until ALL of the following items have been completed and submitted to the Office of Human Resources.

TO BE CHECKED BY HR

REQUIRED FORMS COMPLETED

A. Business papers: **Employee retains all pages except a-h below**

a) Personnel Information (pg 23 & 24)

b) CalPERS Reciprocal Self-Certification Form (pg 29)

c) Loyalty Oath (pg 31)

d) I-9 Employment Eligibility Verification (pg 33- 51)

Employee to complete Section 1 plus top line of 2nd page.

Section 2 to be completed by HR/authorized college staff with appropriate documentation verified.

e) Form W-4 2020 (pg 53 boxes 1-7 must be completed along with signature and date)

f) Form DE4 2020 (pg 57) State Withholding *Newly Required in 2020*

g) Statement Concerning Your Employment in a Job Not Covered by Social Security

(pg 61 & 63 two copies to be signed and dated)

h) Automatic Payroll Deposit Authorization (pg 65) with voided check or banking direct deposit form (Direct deposit not required, see Personnel Information pages)

B. Employment Application (depending on assignment) Please apply online through NeoGov, via the appropriate temp-pool and follow Application Procedures listed.

C. Fingerprint Verification: Request for Live Scan Service Form

Must receive directly from HR personnel, form type is dependent on role. Fingerprinting is not a reimbursable expense. Submit completed form with signature of LiveScan technician to HR Office directly with above documents.

PLEASE DO NOT ROUTE NEW HIRE PAPERWORK PACKET VIA INTEROFFICE MAIL. PLEASE DELIVER DIRECTLY TO HR.

For Supervisor Use

Personnel Action Form (PAF) completed and routed on _______________________. DATE

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NAPA VALLEY COMMUNITY COLLEGE DISTRICT

PROCEDURES FOR IMPLEMENTING

HEALTHY WORKPLACES/HEALTHY FAMILIES ACT OF 2014, PAID SICK LEAVE LAW,

AND PAID JUDICIAL LEAVE FOR PART-TIME, HOURLY NON-ACADEMIC EMPLOYEES

The Healthy Workplaces/Healthy Families Act of 2014, Paid Sick Leave Law, provides the right for

employees to accrue and use sick leave. These procedures outline Napa Valley Community College District

(NVCCD) practices and procedures for implementing the requirements of this Act for part-time, hourly non-

academic employees. These procedures will be provided to hourly employees at time of hire.

Part-time, hourly non-academic employees, hereinafter referred to as hourly employees, are temporary

employees hired to serve for a limited duration in a non-academic assignment paid by the hour or stipend.

Such employees are hired under a written Notice of Assignment, Contract for Services, or Personnel Action

Form (PAF) issued by the Office of Human Resources or a Work Clearance for student workers issued by the

Financial Aid/EOPS Office and are eligible to accrue and use leave outlined in these procedures. Leave

under these procedures may only be used for non-academic hours that were assigned by the supervisor

prior to the absence.

The Healthy Workplaces/Healthy Families Act of 2014, Paid Sick Leave Law, prohibits retaliation or

discrimination against an employee who requests or uses paid sick leave. An employee has the right to file

a complaint with the Labor Commissioner against an employer who retaliates or discriminates against an

employee who requests or uses paid sick leave.

Hourly, non-academic assignments for the purposes of these procedures are defined as all hourly

assignments excluding credit or noncredit instruction, adjunct faculty office hours, counseling, and librarian

services.

Employees serving in multiple assignments for Napa Valley Community College District accrue and use

leave based on the provisions applicable to the specific employee group for the respective assignment.

1.0 SICK LEAVE

1.1 Entitlement and Accrual:

1.1.1 An hourly employee who, on or after July 1, 2015, works for thirty (30) or more days

within a fiscal year from the beginning of employment is entitled to accrue paid sick

leave.

1.1.2 Accrual shall begin on the first day of employment or July 1, 2015, whichever is

later.

1.1.3 An hourly employee may use accrued sick leave beginning on the 90th calendar day

of employment after July 1, 2015 in accordance with Article 1.2.

1.1.4 Paid sick leave accrues at the rate of one (1) hour per every thirty (30) hours

worked.

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1.1.5 The maximum number of sick leave hours an hourly employee can accrue is forty-

eight (48) hours or six (6) days, whichever is greater. Forty-eight (48) will be the

standard maximum number of sick leave hours an hourly employee can accrue

unless Human Resources has been notified by the manager that an hourly

employee’s regular workday exceeds 8 hours per day.

1.1.6 Accrued sick leave will be reported monthly on the hourly employee’s monthly pay

warrant or pay advice based on work hours reported to Payroll by the 12th of the

month.

1.1.7 Accrued paid sick leave up to a maximum of forty-eight (48) hours or six (6) days,

whichever is greater, shall carry over to the following fiscal year of employment.

1.1.8 An hourly employee is not entitled to compensation for accrued, unused paid sick

days upon termination, resignation, or other separation from employment.

1.1.9 Sick leave accrued by an hourly employee is not retained once the hourly employee

terminates, resigns or otherwise separates from employment, except as outlined in

Article 1.1.10 below.

1.1.10 An hourly employee who is rehired within one year of departure date will have

accrued paid sick leave reinstated minus any previously used leave and may use

sick leave without the 90-day waiting period required for employees described in

Articles 1.1.3 and 1.2.1. Reinstated accrued leave is limited to forty-eight (48)

hours or six (6) days, whichever is greater.

1.2 Usage:

1.2.1 An hourly employee may use accrued sick leave at a minimum of one (1) hour per

absence and one-half (1/2) hour increments thereafter beginning on the 90th

calendar day of employment after July 1, 2015. The employee will be paid hourly for

the sick leave hours based on the employee’s regular rate of pay for the position

from which he/she was absent.

1.2.2 An hourly employee may use accrued sick leave for a maximum of twenty-four (24)

hours or three (3) days, whichever is greater, per fiscal year for the purposes stated

below.

1.2.2.1 For diagnosis, care, or treatment of an existing health condition of, or

preventative care for, an employee.

1.2.2.2 For diagnosis, care, or treatment of an existing health condition of, or

preventative care for, an employee’s family member. For the purposes of

these procedures, family member includes parent, child, spouse,

registered domestic partner, parent-in-law, sibling, grandchild, or

grandparent.

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1.2.2.3 For an employee who is a victim of domestic violence, sexual assault, or

stalking, for the purposes described in Labor Code Section 230(c) and

Labor Code Section 230.1(a), which are described below.

1.2.2.3.1 To obtain or attempt to obtain any relief, including, but not

limited to, a temporary restraining order, restraining order, or

other injunctive relief to help ensure the health, safety, or

welfare of the victim or his or her child(ren).

1.2.2.3.2 To seek medical attention for injuries caused by domestic

violence, sexual assault, or stalking.

1.2.2.3.3 To obtain services from a domestic violence shelter,

program, or rape crisis center as a result of domestic

violence, sexual assault, or stalking.

1.2.2.3.4 To obtain psychological counseling related to an experience

of domestic violence, sexual assault, or stalking.

1.2.2.3.5 To participate in safety planning and to take other actions to

increase safety from future domestic violence, sexual

assault, or stalking, including temporary or permanent

relocation.

1.2.3 Leave for these purposes shall be deducted from the employee’s sick leave accrual,

and the reason for the absence must be stated on the absence form.

1.2.4 The District reserves the right to request supporting documentation for any absence

for the purposes described above.

1.2.5 Whenever possible, the hourly employee must contact his/her immediate supervisor

as soon as the need to be absent is known, but in no event less than one-half (1/2)

hour prior to the start of the work assignment, except in case of emergency.

1.2.6 An hourly employee requesting sick leave is not responsible for securing a

replacement worker to cover the time during which the individual uses sick leave.

1.2.7 Hourly employees must request leave by submitting a timecard to report the

previously assigned hours and a Request for Leave form simultaneously to the

employee’s supervisor.

1.2.7 The hourly employee will submit the above documentation in advance to notify the

supervisor of prescheduled appointments or planned long-term absences. For

unplanned absences, leave slips are to be submitted to supervisor within five (5)

days of returning from leave.

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2.0 JUDICIAL LEAVE

2.1 An hourly employee will be provided paid leave for regularly called jury duty and to appear

as a witness in court, other than as a litigant, for reasons not brought about through the

connivance or misconduct of the employee. If possible, the employee shall submit

necessary documentation to support the absence no less than ten (10) days prior to the

beginning date of the leave or appearance as a witness.

2.2 The employee, while serving jury duty, will receive his/her regular rate of pay for the

position from which he/she was absent and must endorse to the District any stipend

received for jury service or inform the Payroll Office in writing of any stipend received. If the

employee fails to endorse to the District any stipend received for jury service, the District

shall deduct from the employee’s pay warrant the amount of such stipend actually paid to

and retained by the employee.

3.0 RESPONSIBILITIES OF MANAGERS

3.1 Managers will not require an hourly employee to find a substitute to replace an employee while

on paid sick leave.

3.2 Retaliation or discrimination against an hourly employee who requests paid sick days or uses

paid sick days or both is prohibited.

3.3 If an hourly employee is unable to complete a timecard and a Request for Leave form and

verbally requests leave, the employee’s supervisor will complete the necessary documentation

on behalf of the employee.

3.4 By signing the timecard and the Request for Leave form, the supervisor of the assignment is

certifying the absence/leave usage, that the leave usage is in accordance with these

procedures, and that the hourly employee was previously approved for the hours prior to the

absence.

3.5 The supervisor shall ensure that leave slips and timecards are provided to the Payroll

Department by the 12th of the month.

3.6 Managers are required to report to Human Resources in writing if an hourly employee’s workday

exceeds eight (8) hours.

OHR – 06/17/15

Note: To be Retained by New Employee

Dear Napa Valley College Employee:

This is to notify you that all employees of Napa Valley College are eligible to make anelective deferral from their salary to the Napa Valley College 403(b) Plan (the "Plan"). The Planalso permits elective deferrals to a 457 account and after-tax Roth contributions.

Per IRS regulations employers are required to provide compliance oversight andmanagement of all of their employees' 403(b) and 457 accounts. Napa Valley College haschosen MidAmerica Administrative & Retirement Solutions, Inc. as our third party administratorfor these plans.

All Plan related transactions (other than investment decisions) must be validated byMidAmerica prior to being processed by payroll or your investment provider. This includes all'distributions, transfers, rollovers, hardships, loans, and salary reduction agreements. To make anelective contribution to the Plan, you must complete a Salary Reduction Agreement and return itto MidAmerica. You may make, change or stop such an election to contribute as often as youwish, and it will be effective when indicated on the Salary Reduction Agreement or the nextapplicable payroll date after it is approved by MidAmerica. For a list of approved investmentproviders and complete instructions on how to enroll in the Plan, please see the attachedAdministrative Procedures for Plan Participants.

MidAmerica's fee for administrative services is $20.00 per year per actively contributingparticipant. All of the approved investment providers on the plan have been requested to pay theadministration fee. Some investment providers will agree to pay the fee but then will deduct theamount from your account. If you have questions regarding this practice please contact yourinvestment representative directly. The list of approved investment providers and whether theywill pay the fee is available on the MidAmerica website.

Such elective contributions are subject to applicable Internal Revenue Code limits and theterms of the Plan. They may also be suspended for 6 months following a distribution to you fromthe Plan on account of hardship. For a copy of the Salary Reduction Agreement or a summary ofthe Plan, or if you have any other questions, please contact MidAmerica Administrative &Retirement Solutions, Inc. at (866) 873-4240.

This Notice is to provide general information regarding availability of the Plan. You should consult withyour own financial, tax, or legal advisor as to whether you should contribute to the Plan. Should there beany difference between the information in this Notice and the Plan, the terms of the Plan will control. Theinformation in this Notice is not intended or written to be used, and cannot be used, for the purpose ofavoiding penalties under the Internal Revenue Code or promoting, marketing or recommending to anytransaction or matter addressed herein.

403(b) and 457 Third Party Administration Services

© MidAmerica Administrative & Retirement Solutions, Inc. Administrative Procedures for Plan Participants

Administrative Procedures for Plan Participants

To Enroll in the 403(b) or 457 Plan – 1. Go to the webpage for your plan (instructions below). 2. Choose an Investment Provider from the approved list for your plan. 3. Contact the Investment Provider directly to establish your 403(b) or 457 account. 4. Once you have established your account, complete and sign the Salary Reduction Agreement

provided on your plan’s webpage. 5. Fax the Salary Reduction Agreement to MidAmerica for processing (Fax: 863-688-4466).

All participant transaction requests and Salary Reduction Agreements (SRA) must be submitted to

MidAmerica for validation prior to being processed by your payroll department or your

Investment Provider. This includes all distributions, rollovers, transfers/exchanges, loans, hardships, or Salary Reduction Agreements. Contact your Investment Provider for all transaction forms such as distribution requests, loan requests, hardship distributions, transfers and exchanges. After completing the transaction request form, submit the paperwork to MidAmerica for compliance review and authorization. Go to www.MidAmerica.biz to access plan information and obtain forms such as Salary Reduction Agreements and Plan Highlights.

Click on Participants 403(b) TPA Services from the right menu Click Here To Go To Your Plan Start typing in your Employer Name until the link appears for your Plan Click on your Plan link to go to your Employer’s customized web page

If you only need to download forms, they are available on this page. Or you can click on your Plan’s customized Spokeskids link for additional information such as:

A complete list of the Investment Providers approved on your plan Videos and FAQs with general information about 403(b) and 457 Plans Retirement Calculator Forms for your plan

Customer Service: 866-873-4240 MidAmerica’s Customer Service Representatives for English and Spanish speaking participants are available: Monday – Thursday 8:30 a.m. – 8:00 p.m. EST Friday 8:30 a.m. – 6:00 p.m. EST

TPA Fax: 863-688-4466

Transactions secure upload website link:

https://www.midamerica.biz/forms/file-upload-pages/403b-transactions/?ssl SRA secure upload website link:

https://www.midamerica.biz/forms/file-upload-pages/403b-sra/?ssl

http://www.midamerica.biz/

https://www.midamerica.biz/forms/file-upload-pages/403b-transactions/?ssl

https://www.midamerica.biz/forms/file-upload-pages/403b-sra/?ssl

*All of Alameda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara, western portion of

Solano County (including Fairfield and points west) and the southern portion of Sonoma County (including

Windsor and points south).

Office of Human Resources

Dear Employee,

The Bay Area Commuter Benefits Program is a new regulation requiring employers with 50 or more full-time employees within the nine bay area counties* to offer commuter benefits to their employees. This program will help improve air quality and reduce traffic congestion by decreasing single-occupant commute trips, while providing tax saving for employees. Napa Valley College is implementing a tax-free commuter benefit program for all eligible employees who commute to work by public transit. Eligible employees are those who work twenty (20) hours or more per week. This benefit allows employees to pay their fare with pre-tax dollars by excluding up to $130 per month ($1,560 per year) from their taxable income. The transportation benefit goes into effect September 30, 2014. Below is a sample schedule of how the benefit will work:

Orders must be entered by the 10th of the month two months prior to the benefit period. For example, to receive an order for use in January, you must place your order before November 10th. In this example, payroll deductions would begin in November and benefits would be distributed on December 22 for use beginning January 1.

Please read the enclosed notification from My Commuter Check (MyCC), which includes information on how the program works and step-by-step instructions on how to register. If you have questions regarding how to place an order, how to register, and/or other concerns, MyCC Customer Support is available Monday-Friday from 5:00 a.m. to 5:00 p.m. (Pacific Time). You can reach them at 888-235-9223 or [email protected].

mailto:[email protected]

Announcing Premium Commuter Benefits for Napa Valley Community College!

About My Commuter Check:

My Commuter Check is brought to you by Edenred - a top global provider of social and employee benefits worldwide. We manage programs that serve 30 million individuals in 40 countries in Europe, Latin America, Asia/Pacific, and North America.

Commuter Benefit Program Overview:

Commuting to work each day can be expensive. The commuter benefit program will help you save money on your commuting costs along with the convenience of automated electronic fulfillment. My Commuter Check provides Vouchers, Debit Cards and electronic loading of select Smart Cards for a number of transit authorities through an easy on-line enrollment and benefit management program. We are also committed to preserving the environment and reducing its carbon footprint and want to encourage employees to contribute to these efforts by taking public transportation. Together we can save money and the environment at the same time.

How Does the Program Work?

Using the My Commuter Check website (see Registration is Easy below), you will create an account and place orders for transit products. My Commuter Check will send your employer information about your selections and instruct them to deduct the proper amounts from your paycheck.

Ordering Vouchers, Smart Cards or Debit Cards:

My Commuter Check is a national service. Our long-standing relationships with transit authorities across the nation enable us to provide electronic loading of smart cards in selected cities. Once you have created your new account, just select the Transit Order button on the left. Select your Greater Metropolitan Area and choose from the following Transit Smart Cards available:

Community Transit METRO (HOUSTON) Pierce Transit

COMPASS Card Metro North Railroad Monthly SFRTA Tri-Rail

CTA - Chicago Card Plus Metro SmarTrip® Card Sound

Foothill Transit (West Covina) Metro (Seattle) TAP Card

Kitsap Transit MTS-SANDAG Clipper (TransLink)

Long Island Rail Road Monthly NCTD-The Coaster Ventura County Transportation Commission

MBTA - CharlieCard ORCA Washington State Ferries

MDTA PATCO

Commuter Check Card for Transit: A re-loadable commuter benefit card that is accepted at Transit Agencies or designated transit retail centers where only transit and vanpool passes, tickets, and fare cards are sold*. The Commuter Check Card can be also used at Fare Vending Machines, which saves you time waiting in line and time locating a customer service desk or staffed sales area.

*For compliance reasons the Commuter Check Card can only be accepted at designated outlets that sell transit products exclusively, such as Transit Stations and Kiosks. Stores that sell other products, such as gift shops and pharmacies, will not accept the Commuter Check Card.

Commuter Check for Transit Vouchers: If you cannot find a transit product on the website, you can order a Commuter Check Voucher to purchase the pass you want. Just select Commuter Check Voucher from the product menu and specify the quantity and denomination(s) you desire. My Commuter Check will send the vouchers to you, and you can use them to purchase transit passes at designated transit retail outlets.

Your Commuter Benefit has some features you need to know about in order to take full advantage of the program:

The program is a monthly program; log in and place an order to be fulfilled on a monthly basis. Orders must be entered by the 10

th of the month two months prior to the benefit period. For example, to receive an order for

use in January, you must place your order before November 10th

Changes must be made online before the cut-off date of the 10

th of the month for the upcoming month.

Use the convenient recurring settings option to request funds to automatically be loaded to your smart card each month. Don’t worry; we’ll email you a reminder so remember to give us a valid email address when you register.

Pre-tax deductions are allowed up to the limit of $130 per month for transit.

No retroactive changes may be made.

Registration is Easy:

Registering and placing orders is easy. Follow these simple steps to get started. Go to: https://www.mycommutercheck.com * * My Commuter Check is designed to work with Microsoft Explorer Version 6.0 and above

From the main landing page, select First time user? from the menu on the left of the page. To register, you will need the following information: Company ID: 109569 First Name: Last Name: Zip Code: 94558

All information must match your employer’s records at the time of eligibility*; this information is used to authenticate you as a user in the system. So, if your employer’s records list you as James instead of Jim, you will want to enter James in the first name field. If you have any trouble with the process, please contact Customer Support at 888.235.9223.

Once you have entered this data, you will advance to another page where you are asked to enter your personal demographic information, set your password, and set your user name. Note that this is the information we will use to contact you about your orders. The system will send email reminders about your orders as well, so make sure to enter a valid email address.

*IMPORTANT: The current mailing address listed under your profile is the employer address (2277 Napa Vallejo Highway, Napa, CA 94558). Be sure to update this information under your account settings to reflect your mailing address; this way information regarding your orders can be mailed directly to your home address.

Important Registration Tips:

Username: Must consist of at least 6 characters (symbols are okay, spaces are not)

Password: Must consist of at least 6 characters

Contacting Customer Support:

Customer Support is available to assist you with registration, placing an order or any other questions or concerns you may have. Our skilled representatives are available Monday through Friday from 5:00 AM to 5:00 PM Pacific Time. You can reach Customer Support as follows:

By Phone: 888.235.9223

By Email: [email protected]

https://www.mycommutercheck.com/

mailto:[email protected]


PERSONNEL INFORMATION Administrator Classified Confidential Salaried Professional Full-Time Instructor

Temporary, Hourly Part-Time Faculty/Substitute

PLEASE PRINT SOCIAL SECURITY NUMBER:

Ms. Mrs.NAME: Mr. Dr.

Last Name First Name Middle Initial

ADDRESS: Street Number and Name Apt. # City State Zip Code

TELEPHONE: Primary: Home Cell Phone Business

Secondary: Home Cell Phone Business

E-MAIL ADDRESS: BIRTH DATE:

Position Start Date:

Position:

Supervisor:

Department:

VERIFIED DISABILITY: Yes No (see reverse for definition)

Gender: Male Female

U.S. Citizen/Resident Alien (holder of form I-551)

Non-resident Alien

EMERGENCY CONTACT INFORMATION RACE/ETHNICITY: Optional. Check all that apply (indicate primary ethnicity).See reverse for definitions.

Name:

Relationship:

Phone Number:

Alternate Phone Number:

Additional Name:

Relationship:

Phone Number :

Are you Hispanic or Latino? Yes No White Black or African American American Indian / Alaskan Native Mexican, Mexican-American, Chicano Central American South American Hispanic Other Filipino Chinese Japanese

Korean Laotian Cambodian Vietnamese Asian Indian Asian Other Guamanian Hawaiian Samoan Pacific Islander, Other

1) Are you currently contributing to, or have your ever been a member of a California Public Retirement system? Yes No Full-time Part-time California Public Employees’ Retirement System (PERS) California State Teachers’ Retirement System (STRS)

2) Have you retired from California Public Employees’ Retirement System (PERS)? Yes No If you answered yes to the above question, you must complete and submit the Retired Annuitant Certification

form on the following page.

3) Have you retired from California State Teachers’ Retirement System (STRS)? Yes No

4) Have you requested a refund of contributions from California Public Employees’ Retirement System (PERS)? Yes No

5) Have you requested a refund of contributions from California State Teachers’ Retirement System (STRS)? Yes No

PERSONNEL INFORMATION Page 2

6) Can you communicate effectively in a language other than English, please indicate: 7) Are you currently employed as a teacher in a California public school district (K-14)? Yes No

If yes, what district? What percentage of time?

I WISH TO HAVE MY CHECK DISBURSED AS FOLLOWS:

Pick up check at Business Office (will be mailed if not picked up within 60 days)

Mail check to: Address on previous page Other:

Electronic money transfer:

You must attach the Automatic Payroll Deposit Authorization form and a voided blank check.

Until the electronic money transfer goes into effect:

I wish to pick up my check(s) at Business Office.

I wish to have my check(s) mailed.

Signature: Date:

HR/Payroll Use Only:

Pay rate: Range Step $_________ per month OR $_______ per hour.

Number of hours per day ________________ / number of hours per week __________________.

ETHNIC GROUP DEFINITIONS

American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America), and who maintains a tribal affiliation or community attachment.

Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, and Vietnam. Black or African American A person having origins in any of the Black racial groups of Africa. Hispanic/Latino All persons of Chicano, Mexican, Puerto Rican, Cuban, Central or South American origin, or other Spanish cultures or origins, regardless of race. Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

DEFINITION OF PERSON WITH A DISABILITY One who (1) has a physical or mental impairment which substantially limits one or more of such person’s major life activities, (2) has a record of impairment, or (3) is regarded as having such impairment. (Title V, 53001j) Rev. 6/2009;2/2013; 3/2017; 1/2018

2277 Napa-Vallejo Highway, Napa, CA 94558 (707) 256-7100 www.napavalley.edu


RETIRED ANNUITANT CERTIFICATION

California law prohibits the appointment of a retired annuitant by a CalPERS employer if, during the 12 month period prior to appointment, the retiree received unemployment insurance compensation for prior retired annuitant employment with any public employer. If you are working as a retired annuitant and it is discovered that during the previous 12 months you were paid unemployment insurance compensation based on prior retired annuitant employment with any CalPERS employer, your employment must be terminated on the last day of the current pay period. You will not be eligible for appointment as a retired annuitant with any CalPERS employer for 12 months following the termination date of the current employment. Violation of this unemployment insurance compensation restriction does not result in mandatory reinstatement from retirement. I certify that as a retired annuitant, I am in compliance with this requirement. Employee Name: Signature: Date:

Payroll Department

Page 1 of 4

Dear Napa Valley College Employee, You are being provided with the background, explanation, and instructions for the CalPERS Reciprocal Self-Certification Form (PERS-CASD 901). With the implementation of The Public Employees’ Pension Reform Act of 2013 (PEPRA) on January 1, 2013, CalPERS requires that employers determine the applicable retirement benefit formula for new employees who may qualify for enrollment in the CalPERS Retirement system. If your position qualifies for membership in the CalPERS Retirement system, the Reciprocal Self-Certification form allows you to provide essential information to Napa Valley College and will be used to enroll you into CalPERS membership, if applicable. This information will assist in identifying your retirement benefit level. Reciprocity among public retirement systems is to allow members to separate from one public employer and enter into employment with another public employer within a specific time limit without losing valuable retirement and related benefit rights. Within 10 business days of employment you must complete, sign, date, and submit to Human Resources the Reciprocal Self-Certification form. When completing the form, reference the attached list of qualifying Public Retirement Systems in California. If applicable, list your previous membership date(s) in the qualifying Public Retirement System and your permanent separation date(s); OR indicate that you are not a current or past member of a qualifying Public Retirement System. The completion of the Reciprocal Self-Certification From does not establish reciprocity and is not a request to establish reciprocity. In order to request that reciprocity be established, visit the CalPERS website, www.calpers.ca.gov and download the publication When You Change Retirement Systems. It is the responsibility of the employee to complete and send the form, Confirmation of Intent to Establish Reciprocity When Changing Retirement Systems to CalPERS.

Active Duty Military Service Credit CalPERS members have the right to purchase their past military service credit through CalPERS. Please see the CalPERS publication 15 titled A Guide to Your CalPERS Military Service Credit Options which is available online through the CalPERS website. This publication provides valuable information for members who are requesting to purchase active duty military service credit prior to CalPERS membership, and/or military leave of absence service credit. This publication also provides the necessary form to request service credit information.

http://v.'',,vw',calpers.ca.gov!indcx.jsp?bc=/member/retiremem/reciprocity.xml&pst=ACT&pc,..

PERS-EAMD-801 (6/2018) Page 2 of 4

List of Qualifying Public Retirement Systems in California

Name of Public Retirement System Qualifications: Alameda County Employees’ Retirement Association^

City and County of San Francisco Employees’ Retirement System*

City of Concord Retirement System*

City of Costa Mesa Public Retirement System* Safety only

City of Fresno Retirement System

City of Pasadena Fire and Police Retirement System Fire and police only

City of San Clemente* Non-safety (miscellaneous) only

Contra Costa County Employees’ Retirement Association^

Contra Costa Water District

East Bay Municipal Utility District

East Bay Regional Park District Safety only

Fresno County Employees’ Retirement Association^

Imperial County Employees’ Retirement Association^

Judges Retirement System II

Kern County Employees’ Retirement System^

Legislators’ Retirement System

Los Angeles City Employees’ Retirement System Non-safety (miscellaneous) only; L.A. Fire and Police Pension System and L.A. Water and Power Employees’ Retirement System not eligible

Los Angeles County Employees’ Retirement Association^

Los Angeles County Metropolitan Transportation Authority Non-contract Employees’ Retirement Income Plan, formerly Southern California Rapid Transit District

Marin County Employees’ Retirement Association^

Mendocino County Employees’ Retirement Association^

Merced County Employees’ Retirement Association^

Oakland Municipal Employees’ Retirement System (City of Oakland)

Non-safety (miscellaneous) only

Orange County Employees’ Retirement System^

Sacramento City Employees’ Retirement System*

Sacramento County Employees’ Retirement System^ Defined benefit plan only; cash balance plans not eligible

San Bernardino County Retirement Association^

San Diego City Employees’ Retirement System Defined benefit plan only; cash balance plans not eligible

San Diego County Employees’ Retirement Association^

San Joaquin County Employees’ Retirement Association^

San Jose Federated City Employees’ Retirement System

San Luis Obispo County Pension Trust

San Mateo County Employees’ Retirement Association^

Santa Barbara County Employees’ Retirement System^

Sonoma County Employees’ Retirement Association^

Stanislaus County Employees’ Retirement Association^

State Teachers’ Retirement System Defined benefit plan only; cash balance plans not eligible

Tulare County Employees’ Retirement Association^

University of California Retirement Program Defined benefit plan only; cash balance plans not eligible

Ventura County Employees’ Retirement Association^

*=Also CalPERS-covered agency ^=1937 Act Counties

NAPA VALLEY COMMUNITY COLLEGE DISTRICT

LOYALTY OATH

I, _________________________________________, do solemnly affirm that I (Please Print)

will support and defend the Constitution of the United States and the Constitution of

the State of California against all enemies, foreign and domestic; that I will bear true

faith and allegiance to the Constitution of the United States and the Constitution of

the State of California; that I take this obligation freely, without any mental reservation

or purpose of evasion; and that I will well and faithfully discharge the duties upon

which I am about to enter.

_________________________________________ Signature

_________________________________________

Date

Execution of this oath is a condition of employment by a public agency pursuant to Article 20, Section 3, of the Constitution of the State of California.

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

Form I-9 10/21/2019 Page 1 of 3

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

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

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

Date of Birth (mm/dd/yyyy)

- -

Employee's E-mail Address Employee's Telephone Number U.S. Social Security Number

1. A citizen of the United States

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

3. A lawful permanent resident

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

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

(Alien Registration Number/USCIS Number):

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

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

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

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

1. Alien Registration Number/USCIS Number:

2. Form I-94 Admission Number:

3. Foreign Passport Number:

Country of Issuance:

OR

OR

QR Code - Section 1 Do Not Write In This Space

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

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

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

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

Employer Completes Next Page

Form I-9 10/21/2019 Page 2 of 3

USCIS Form I-9

OMB No. 1615-0047 Expires 10/31/2022

Employment Eligibility Verification Department of Homeland Security

U.S. Citizenship and Immigration Services

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

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

Citizenship/Immigration Status

List AIdentity and Employment Authorization Identity Employment Authorization

OR List B AND List C

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

Document Title

Issuing Authority

Document Number

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

Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


Document Title

Issuing Authority

Document Number


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

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

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

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

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

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

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

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

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

LISTS OF ACCEPTABLE DOCUMENTSAll documents must be UNEXPIRED

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

LIST A

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

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

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

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

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

Documents that Establish Both Identity and

Employment Authorization

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

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

and(2) An endorsement of the alien's

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

a. Foreign passport; and

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

listed above:

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

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

3. School ID card with a photograph

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner Card

8. Native American tribal document

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

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

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish Identity

LIST B

OR AND

LIST C

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

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

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

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

4. Native American tribal document

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

Documents that Establish Employment Authorization

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

(2) VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Page 3 of 3Form I-9 10/21/2019

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

Refer to the instructions for more information about acceptable receipts.

EMPLOYEE’S WITHHOLDING ALLOWANCE CERTIFICATE

1. Number of allowances for Regular Withholding Allowances, Worksheet A

Number of allowances from the Estimated Deductions, Worksheet BTotal Number of Allowances (A + B) when using the CaliforniaWithholding Schedules for 2019

OR2. Additional amount of state income tax to be withheld each pay period (if employer agrees), Worksheet C

OR3. I certify under penalty of perjury that I am not subject to California withholding. I meet the conditions set forth under

the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act. (Check box here) Under the penalties of perjury, I certify that the number of withholding allowances claimed on this certificate does not exceed the number to which I am entitled or, if claiming exemption from withholding, that I am entitled to claim the exempt status.

Signature Date

Employer’s Name and Address California Employer Payroll Tax Account Number

cut here

Give the top portion of this page to your employer and keep the remainder for your records.

YOUR CALIFORNIA PERSONAL INCOME TAX MAY BE UNDERWITHHELD IF YOU DO NOT FILE THIS DE 4 FORM.

IF YOU RELY ON THE FEDERAL FORM W-4 FOR YOUR CALIFORNIA WITHHOLDING ALLOWANCES, YOUR CALIFORNIA STATE PERSONAL INCOME TAX MAY BE UNDERWITHHELD AND YOU MAY OWE MONEY AT THE END OF THE YEAR.

PURPOSE: This certificate, DE 4, is for California Personal Income Tax (PIT) withholding purposes only. The DE 4 is used to compute the amount of taxes to be withheld from your wages, by your employer, to accurately reflect your state tax withholding obligation.

You should complete this form if either:

(1) You claim a different marital status, number of regular allowances,or different additional dollar amount to be withheld for California PITwithholding than you claim for federal income tax withholding or,

(2) You claim additional allowances for estimated deductions.

THIS FORM WILL NOT CHANGE YOUR FEDERAL WITHHOLDING ALLOWANCES.

The federal Form W-4 is applicable for California withholding purposes if you wish to claim the same marital status, number of regular allowances, and/or the same additional dollar amount to be withheld for state and federal purposes. However, federal tax brackets and withholding methods do not reflect state PIT withholding tables. If you rely on the number of withholding allowances you claim on your Form W-4 withholding allowance

City, State, and ZIP Code

Home Address (Number and Street or Rural Route)

Type or Print Your Full Name Your Social Security Number

Filing Status Withholding Allowances

SINGLE or MARRIED (with two or more incomes)

MARRIED (one income)

HEAD OF HOUSEHOLD

certificate for your state income tax withholding, you may be significantly underwithheld. This is particularly true if your household income is derived from more than one source.

CHECK YOUR WITHHOLDING: After your Form W-4 and/or DE 4 takes effect, compare the state income tax withheld with your estimated total annual tax. For state withholding, use the worksheets on this form.

EXEMPTION FROM WITHHOLDING: If you wish to claim exempt, complete the federal Form W-4. You may claim exempt from withholding California income tax if you did not owe any federal income tax last year and you do not expect to owe any federal income tax this year. The exemption is good for one year. If you continue to qualify for the exempt filing status, a new Form W-4 designating EXEMPT must be submitted by February 15 each year to continue your exemption. If you are not having federal income tax withheld this year but expect to have a tax liability next year, you are required to give your employer a new Form W-4 by December 1.

DE 4 Rev. 47 (12-18) (INTERNET) Page 1 of 4 CU

EXEMPTION FROM WITHHOLDING (continued): Under the Service Member Civil Relief Act, as amended by the Military Spouses Residency Relief Act, you may be exempt from California income tax on your wages if (i) your spouse is a member of the armed forces present in California in compliance with military orders; (ii) you are present in California solely to be with your spouse; and (iii) you maintain your domicile in another state. If you claim exemption under this act, check the box on Line 3. You may be required to provide proof of exemption upon request.

IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA RESIDENT INCOME TAX RETURN OR CALL THE FRANCHISE TAX BOARD (FTB).

IF YOU ARE CALLING FROM WITHIN THE UNITED STATES 1-800-852-5711 (voice)1-800-822-6268 (TTY)

IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES (Not Toll Free) 1-916-845-6500

The California Employer’s Guide, DE 44, provides the income tax withholding tables. This publication may be found on the Employment Development Department (EDD) website at www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm. To assist you in calculating your tax liability, please visit the FTB website at www.ftb.ca.gov/individuals/index.shtml.

PENALTY: You may be fined $500 if you file, with no reasonable basis, a DE 4 that results in less tax being withheld than is properly allowable. In addition, criminal penalties apply for willfully supplying false or fraudulent information or failing to supply information requiring an increase in withholding. This is provided by section 13101 of the California Unemployment Insurance Code and section 19176 of the Revenue and Taxation Code.

NOTIFICATION: If the IRS instructs your employer to withhold federal income tax based on a certain withholding status, your employer is required to use the same withholding status for state income tax withholding.

The burden of proof rests with the employee to show the correct California Income Tax Withholding. Pursuant to section 4340-1(e) of Title 22, California Code of Regulations (CCR), the FTB or the EDD may, by special direction in writing, require an employer to submit a Form W-4 or DE 4 when such forms are necessary for the administration of the withholding tax programs.

DE 4 Rev. 47 (12-18) (INTERNET) Page 2 of 4

http://www.edd.ca.gov/Payroll_Taxes/Forms_and_Publications.htm

http://www.ftb.ca.gov/individuals/index.shtml

http://www.edd.ca.gov/pdf_pub_ctr/de44.pdf

https://govt.westlaw.com/calregs/Search/Index

https://govt.westlaw.com/calregs/Search/Index

http://leginfo.legislature.ca.gov/faces/codes.xhtml


INSTRUCTIONS — 1 — ALLOWANCES*

When determining your withholding allowances, you must consider your personal situation:— Do you claim allowances for dependents or blindness?— Will you itemize your deductions?— Do you have more than one income coming into the household?

TWO-EARNERS/MULTIPLE INCOMES: When earnings are derived from more than one source, underwithholding may occur. If you have a working spouse or more than one job, it is best to check the box “SINGLE or MARRIED (with two or more incomes).” Figure the total number of allowances you are entitled to claim on all jobs using only one DE 4 form. Claim allowances with one employer. Do not claim the same allowances with more than one employer. Your withholding will usually be most accurate when all allowances are claimed on the DE 4 or Form W-4 filed for the highest paying job and zero allowances are claimed for the others.

MARRIED BUT NOT LIVING WITH YOUR SPOUSE: You may check the “Head of Household” marital status box if you meet all of the following tests:(1) Your spouse will not live with you at any time during the year;(2) You will furnish over half of the cost of maintaining a home

for the entire year for yourself and your child or stepchild whoqualifies as your dependent; and

(3) You will file a separate return for the year.

HEAD OF HOUSEHOLD: To qualify, you must be unmarried or legally separated from your spouse and pay more than 50% of the costs of maintaining a home for the entire year for yourself and your dependent(s) or other qualifying individuals. Cost of maintaining the home includes such items as rent, property insurance, property taxes, mortgage interest, repairs, utilities, and cost of food. It does not include the individual’s personal expenses or any amount which represents value of services performed by a member of the household of the taxpayer.

(A) Allowance for yourself — enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (A)

(B) Allowance for your spouse (if not separately claimed by your spouse) — enter 1 . . . . . . . . . . . . . . . (B)

(C) Allowance for blindness — yourself — enter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (C)

(D) Allowance for blindness — your spouse (if not separately claimed by your spouse) — enter 1 . . . . . . . . (D)

(E) Allowance(s) for dependent(s) — do not include yourself or your spouse . . . . . . . . . . . . . . . . . . . (E)

(F) Total — add lines (A) through (E) above . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (F)

INSTRUCTIONS — 2 — ADDITIONAL WITHHOLDING ALLOWANCES

If you expect to itemize deductions on your California income tax return, you can claim additional withholding allowances. Use Worksheet B to determine whether your expected estimated deductions may entitle you to claim one or more additional withholding allowances. Use last year’s FTB Form 540 as a model to calculate this year’s withholding amounts.

Do not include deferred compensation, qualified pension payments, or flexible benefits, etc., that are deducted from your gross pay but are not taxed on this worksheet.

You may reduce the amount of tax withheld from your wages by claiming one additional withholding allowance for each $1,000, or fraction of $1,000, by which you expect your estimated deductions for the year to exceed your allowable standard deduction.

WORKSHEET B ESTIMATED DEDUCTIONS

WORKSHEET A REGULAR WITHHOLDING ALLOWANCES

1. Enter an estimate of your itemized deductions for California taxes for this tax year as listed in theschedules in the FTB Form 540 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1. __________________________

2. Enter $8,802 if married filing joint with two or more allowances, unmarried head of household, orqualifying widow(er) with dependent(s) or $4,401 if single or married filing separately, dual income married, or married with multiple employers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – 2. __________________________

3. Subtract line 2 from line 1, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = 3. __________________________

4. Enter an estimate of your adjustments to income (alimony payments, IRA deposits) . . . . . . . . . . . . + 4. __________________________

5. Add line 4 to line 3, enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = 5. __________________________

6. Enter an estimate of your nonwage income (dividends, interest income, alimony receipts) . . . . . . . . . – 6. __________________________

7. If line 5 is greater than line 6 (if less, see below);Subtract line 6 from line 5, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . = 7. __________________________

8. Divide the amount on line 7 by $1,000, round any fraction to the nearest whole number . . . . . . . . . 8. __________________________Enter this number on line 1 of the DE 4. Complete Worksheet C, if needed.

9. If line 6 is greater than line 5;Enter amount from line 6 (nonwage income) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9. __________________________

10. Enter amount from line 5 (deductions) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10. __________________________

11. Subtract line 10 from line 9, enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11. __________________________Complete Worksheet C

*Wages paid to registered domestic partners will be treated the same for state income tax purposes as wages paid to spouses for California PIT withholding and PIT wages. This law does not impact federal income tax law. A registered domestic partner means an individual partner in a domestic partner relationship within the meaning of section 297 of the Family Code. For more information, please call our Taxpayer Assistance Center at 1-888-745-3886.



WORKSHEET C TAX WITHHOLDING AND ESTIMATED TAX

1. Enter estimate of total wages for tax year 2019 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.

2. Enter estimate of nonwage income (line 6 of Worksheet B) . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.

3. Add line 1 and line 2. Enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.

4. Enter itemized deductions or standard deduction (line 1 or 2 of Worksheet B, whichever is largest) . . . . . . 4.

5. Enter adjustments to income (line 4 of Worksheet B) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.

6. Add line 4 and line 5. Enter sum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.

7. Subtract line 6 from line 3. Enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7.

8. Figure your tax liability for the amount on line 7 by using the 2019 tax rate schedules below . . . . . . . . . 8.

9. Enter personal exemptions (line F of Worksheet A x $129.80) . . . . . . . . . . . . . . . . . . . . . . . . . 9.

10. Subtract line 9 from line 8. Enter difference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10.

11. Enter any tax credits. (See FTB Form 540) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.

12. Subtract line 11 from line 10. Enter difference. This is your total tax liability . . . . . . . . . . . . . . . . . . 12.

13. Calculate the tax withheld and estimated to be withheld during 2019. Contact your employer torequest the amount that will be withheld on your wages based on the marital status and number ofwithholding allowances you will claim for 2019. Multiply the estimated amount to be withheld bythe number of pay periods left in the year. Add the total to the amount already withheld for 2019 . . . . . . . 13.

14. Subtract line 13 from line 12. Enter difference. If this is less than zero, you do not need to have additionaltaxes withheld . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14.

15. Divide line 14 by the number of pay periods remaining in the year. Enter this figure on line 2 of the DE 4 . . . 15.

NOTE: Your employer is not required to withhold the additional amount requested on line 2 of your DE 4. If your employer does not agree to withhold the additional amount, you may increase your withholdings as much as possible by using the “single” status with “zero” allowances. If the amount withheld still results in an underpayment of state income taxes, you may need to file quarterly estimates on Form 540-ES with the FTB to avoid a penalty.

THESE TABLES ARE FOR CALCULATING WORKSHEET C AND FOR 2019 ONLY

IF YOU NEED MORE DETAILED INFORMATION, SEE THE INSTRUCTIONS THAT CAME WITH YOUR LAST CALIFORNIA RESIDENT INCOME TAX RETURN OR CALL THE FTB:

IF YOU ARE CALLING FROM WITHIN THE UNITED STATES 1-800-852-5711 (voice)1-800-822-6268 (TTY)

IF YOU ARE CALLING FROM OUTSIDE THE UNITED STATES(Not Toll Free) 1-916-845-6500

The DE 4 information is collected for purposes of administering the PIT law and under the authority of Title 22, CCR, section 4340-1, and the California Revenue and Taxation Code, including section 18624. The Information Practices Act of 1977 requires that individuals be notified of how information they provide may be used. Further information is contained in the instructions that came with your last California resident income tax return.

MARRIED FILING JOINT OR QUALIFYING WIDOW(ER) TAXPAYERS

IF THE TAXABLE INCOME IS COMPUTED TAX IS

OVER BUT NOTOVER

OF AMOUNT PLUSOVER . . .

$0 $17,088 ...$17,088 $40,510 ...$40,510 $63,938 ...$63,938 $88,754 ...$88,754 $112,170 ...

$112,170 $572,984 ...$572,984 $687,576 ...$687,576 $1,000,000 ...

$1,000,000 $1,145,961 ... $1,145,961 and over

1.100% $0 $0.00 2.200% $17,088 $187.97 4.400% $40,510 $703.25 6.600% $63,938 $1,734.08 8.800% $88,754 $3,371.94 10.230% $112,170 $5,432.55 11.330% $572,984 $52,573.82 12.430% $687,576 $65,557.09 13.530% $1,000,000 $104,391.39 14.630% $1,145,961 $124,139.90

SINGLE PERSONS, DUAL INCOME MARRIED WITH MULTIPLE EMPLOYERS


OVER BUT NOTOVER


$0 $8,544 ...$8,544 $20,255 ...

$20,255 $31,969 ...$31,969 $44,377 ...$44,377 $56,085 ...$56,085 $286,492 ...

$286,492 $343,788 ...$343,788 $572,980 ...$572,980 $1,000,000 ...

$1,000,000 and over...

1.100% $0 $0.00 2.200% $8,544 $93.98 4.400% $20,255 $351.62 6.600% $31,969 $867.04 8.800% $44,377 $1,685.97 10.230% $56,085 $2,716.27 11.330% $286,492 $26,286.91

12.430% $343,788 $32,778.55 13.530% $572,980 $61,267.12

14.630% $1,000,000 $119,042.93

UNMARRIED HEAD OF HOUSEHOLD


OVER BUT NOTOVER


$0 $17,099 ...$17,099 $40,512 ...$40,512 $52,224 ...$52,224 $64,632 ...$64,632 $76,343 ...$76,343 $389,627 ...

$389,627 $467,553 ...$467,553 $779,253 ...$779,253 $1,000,000 ...

$1,000,000 and over

1.100% $0 $0.00 2.200% $17,099 $188.09 4.400% $40,512 $703.18 6.600% $52,224 $1,218.51 8.800% $64,632 $2,037.44 10.230% $76,343 $3,068.01 11.330% $389,627 $35,116.96 12.430% $467,553 $43,945.98 13.530% $779,253 $82,690.29

14.630% $1,000,000 $112,557.36


Form SSA-1945 (01-2013) Destroy Prior Editions

Social Security Administration

Statement Concerning Your Employment in a Job Not Covered by Social Security

Employee Name Employee ID#

Employer Name Employer ID#

Your earnings from this job are not covered under Social Security. When you retire, or if you become disabled, you may receive a pension based on earnings from this job. If you do, and you are also entitled to a benefit from Social Security based on either your own work or the work of your husband or wife, or former husband or wife, your pension may affect the amount of the Social Security benefit you receive. Your Medicare benefits, however, will not be affected. Under the Social Security law, there are two ways your Social Security benefit amount may be affected.

Windfall Elimination Provision Under the Windfall Elimination Provision, your Social Security retirement or disability benefit is figured using a modified formula when you are also entitled to a pension from a job where you did not pay Social Security tax. As a result, you will receive a lower Social Security benefit than if you were not entitled to a pension from this job. For example, if you are age 62 in 2013, the maximum monthly reduction in your Social Security benefit as a result of this provision is $395.50. This amount is updated annually. This provision reduces, but does not totally eliminate, your Social Security benefit. For additional information, please refer to Social Security Publication, “Windfall Elimination Provision.”

Government Pension Offset Provision Under the Government Pension Offset Provision, any Social Security spouse or widow(er) benefit to which you become entitled will be offset if you also receive a Federal, State or local government pension based on work where you did not pay Social Security tax. The offset reduces the amount of your Social Security spouse or widow(er) benefit by two-thirds of the amount of your pension.

For example, if you get a monthly pension of $600 based on earnings that are not covered under Social Security, two-thirds of that amount, $400, is used to offset your Social Security spouse or widow(er) benefit. If you are eligible for a $500 widow(er) benefit, you will receive $100 per month from Social Security ($500 - $400=$100). Even if your pension is high enough to totally offset your spouse or widow(er) Social Security benefit, you are still eligible for Medicare at age 65. For additional information, please refer to Social Security Publication, “Government Pension Offset.”

For More Information Social Security publications and additional information, including information about exceptions to each provision, are available at www.socialsecurity.gov. You may also call toll free 1-800-772-1213, or for the deaf or hard of hearing call the TTY number 1-800-325-0778, or contact your local Social Security office.

I certify that I have received Form SSA-1945 that contains information about the possible effects of the Windfall Elimination Provision and the Government Pension Offset Provision on my potential future Social Security Benefits.

Signature of Employee Date

Rev 06/04/2020

Employee Direct Deposit Authorization

Employee Name : ______________________________________ Employee ID # : ___________________

Action Requested: Start Change Cancel Please fill out, sign the bottom of this form, and return to the payroll office along with a VOIDED CHECK(S) from your account(s). The system requires that we test each new account as it is set up so you should expect that direct deposit to take effect no earlier than the second payday after our receipt of this form. You may split the direct deposit of your net pay up to three different banks. You must specify a dollar amount for account 1 and account 2. The remainder of your net pay will be deposited to the third account. You may not split your net pay between accounts at the same bank, as most banks have a process for automatic transfers from one account to another. Account 1

Bank Name : _____________________________________ Account Type : Checking Savings

Deposit Amount : Net Pay Specific Dollar Amount $ __________________ Account 2


Deposit Amount : Specific Dollar Amount $ __________________ Remainder of Net Pay Account 3


Deposit Amount : Remainder of Net Pay Please indicate if you would like to pick up check or have check mailed until the direct deposit goes into effect. This is to authorize Napa Valley College to provide for direct deposit of any wages due me, less the mandatory or authorized withholding(s), deductions and/or corrections to previous deposits, in the above designated account. If any action taken by me results in a rejection of a direct deposit, I understand that Napa Valley College assumes no responsibility for processing a supplemental salary or wage payment until the amount of the rejected deposit is returned to Napa Valley College by the financial institution. Employee Signature: ________________________________ Date: ______________________________