I-9: Employment Eligibility Verification

Employment Eligibility Verification

USCIS Form I-9
Department of Homeland Security

U.S. Citizenship and Immigration Services
START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the instructions - Click here for link to instructions

ANTI-DISCRIMINATION NOTICE: All employees can choose which documentation to present for form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specicify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.
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)
Name*

First Name (Given Name)Last Name (Family Name)
Middle Initial
Other Last Names Used (if any)
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
Address*

Street Number and Name

Apt. Number

City or TownState (Use only 2 Letters)

Zip CodeCountry
U.S. Social Security Number*
Employee's Email Address*
example@example.com
Employee's Telephone Number*
(555) 555-5555
I am aware that federal law provides for imprisonment and/or fines for false statements or the use of false documents, in connection with the completion of this form. I attest, under penalty of prejury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.
Check one of the following boxes to attest to your citizenship or immigration status*

1. A citizen of the United States2. A noncitizen national of the United States (See instructions)3. A lawful permanent resident (Alien Registration Number/USCIS Number)4. A noncitizen (other than Items Numbers 2. and 3. above) authorized to work until (exp. date, if any)
If you selected 3. a lawful permanent resident, Enter USCIS or A-Number
Expiration date if applicable, mm/dd/yyyy
If you check Item Number 4., enter one of these:
1. USCIS A-Number
2. Form I 94 Admission Number:
3. Foreign Passport Number and Country of Issuance:
Signature of Employee*

Clear
Today's Date*

MonthDayYear
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

Clear
Today's Date (mm/dd/yyyy)

MonthDayYear
Date
Preparer Name

First Name (Given Name)Middle NameLast Name (Family Name)
Preparer Address

Address (Street Number and Name)

Street Address Line 2

City or TownState

ZIP CodeCountry
Emerest Home Care of Connecticut LLC
92
Should be Empty:

Employment Eligibility Verification

Department of Homeland Security

Section 1. Employee Information and Attestation